Syphilis: Difference between revisions

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Template:Short description Template:Good article Template:Pp Template:Use dmy dates Template:Cs1 config Template:Infobox medical condition (new)

Syphilis (Template:IPAc-en) is a sexually transmitted infection caused by the bacterium Treponema pallidum subspecies pallidum.^[1] The signs and symptoms depend on the stage it presents: primary, secondary, latent or tertiary.^[1]^[2] The primary stage classically presents with a single chancre (a firm, painless, non-itchy skin ulceration usually between 1 cm and 2 cm in diameter), though there may be multiple sores.^[2] In secondary syphilis, a diffuse rash occurs, which frequently involves the palms of the hands and soles of the feet.^[2] There may also be sores in the mouth or vagina.^[2] Latent syphilis has no symptoms and can last years.^[2] In tertiary syphilis, there are gummas (soft, non-cancerous growths), neurological problems, or heart symptoms.^[3] Syphilis has been known as "the great imitator", because it may cause symptoms similar to many other diseases.^[2]^[3]

Syphilis is most commonly spread through sexual activity.^[2] It may also be transmitted from mother to baby during pregnancy or at birth, resulting in congenital syphilis.^[2]^[4] Other diseases caused by Treponema bacteria include yaws (T. pallidum subspecies pertenue), pinta (T. carateum), and nonvenereal endemic syphilis (T. pallidum subspecies endemicum).^[3] These three diseases are not typically sexually transmitted.^[5] Diagnosis is usually made by using blood tests; the bacteria can also be detected using dark field microscopy.^[2] The Centers for Disease Control and Prevention (U.S.) recommends for all pregnant women to be tested.^[2]

The risk of sexual transmission of syphilis can be reduced by using a latex or polyurethane condom.^[2] Syphilis can be effectively treated with antibiotics.^[6] The preferred antibiotic for most cases is benzathine benzylpenicillin injected into a muscle.^[6] In those who have a severe penicillin allergy, doxycycline or tetracycline may be used.^[6] In those with neurosyphilis, intravenous benzylpenicillin or ceftriaxone is recommended.^[6] During treatment, people may develop fever, headache, and muscle pains, a reaction known as Jarisch–Herxheimer.^[6]

In 2015, about 45.4 million people had syphilis infections,^[7] of which six million were new cases.^[8] During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.^[9]^[10] After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with human immunodeficiency virus (HIV).^[3]^[11] This is believed to be partly due to unsafe drug use, increased prostitution, and decreased use of condoms.^[12]^[13]^[14] Template:TOC limit

Signs and symptoms

File:Primary stage syphilis sore (chancre) on the surface of a tongue-CDC.jpg

Primary syphilis on a tongue

Syphilis can present in one of four different stages: primary, secondary, latent, and tertiary, and may also occur congenitally.^[15] There may be no symptoms.^[16] It was referred to as "the great imitator" by Sir William Osler due to its varied presentations.^[3]^[17]^[18]

Primary

File:Chancres on the penile shaft due to a primary syphilitic infection caused by Treponema pallidum 6803 lores.jpg

Chancre on a penis due to primary syphilis, 1978

Primary syphilis is typically acquired by direct sexual contact with the infectious lesions of another person.^[19] Approximately 2–6 weeks after contact (with a range of 10–90 days) a skin lesion, called a chancre, appears at the site and this contains infectious bacteria.^[20]^[21] This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders approximately 0.3–3.0 cm in size.^[3] The lesion may take on almost any form.^[22] In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer.^[22] Occasionally, multiple lesions may be present (~40%),^[3] with multiple lesions being more common when coinfected with HIV.^[22] Lesions may be painful or tender (30%), and they may occur in places other than the genitals (2–7%).^[22] The most common location in women is the cervix (44%), the penis in heterosexual men (99%), and anally and rectally in men who have sex with men (34%).^[22] Lymph node enlargement frequently (80%) occurs around the area of infection,^[3] occurring seven to 10 days after chancre formation.^[22] The lesion may persist for three to six weeks if left untreated.^[3]

Secondary

File:Secondary Syphilis on palms CDC 6809 lores.rsh.jpg

Typical presentation of secondary syphilis with a rash on the palms of the hands, 1967

File:Syphilis second state 2.jpg

Reddish papules and nodules over much of the body due to secondary syphilis

Secondary syphilis occurs approximately four to ten weeks after the primary infection.^[3] While secondary disease is known for the many different ways it can manifest, symptoms most commonly involve the skin, mucous membranes, and lymph nodes.^[23] There may be a symmetrical, reddish-pink, non-itchy rash on the trunk and extremities, including the palms and soles.^[3]^[24] The rash may become maculopapular or pustular.^[3] It may form flat, broad, whitish, wart-like lesions on mucous membranes, known as condyloma latum.^[3] All of these lesions harbor bacteria and are infectious.^[3] Other symptoms may include fever, sore throat, malaise, weight loss, hair loss, and headache.^[3] Rare manifestations include liver inflammation, kidney disease, joint inflammation, periostitis, inflammation of the optic nerve, uveitis, and interstitial keratitis.^[3]^[25] The acute symptoms usually resolve after three to six weeks;^[25] about 25% of people may present with a recurrence of secondary symptoms.^[23]^[26] Many people who present with secondary syphilis (40–85% of women, 20–65% of men) do not report previously having had the classical chancre of primary syphilis.^[23]

Latent

Latent syphilis is defined as having serologic proof of infection without symptoms of disease.^[19] It develops after secondary syphilis and is divided into early latent and late latent stages.^[27] Early latent syphilis is defined by the World Health Organization as less than 2 years after original infection.^[27] Early latent syphilis is infectious as up to 25% of people can develop a recurrent secondary infection (during which bacteria are actively replicating and are infectious).^[27] Two years after the original infection the person will enter late latent syphilis and is not as infectious as in the early phase.^[25]^[28] The latent phase of syphilis can last many years after which, without treatment, approximately 15–40% of people can develop tertiary syphilis.^[29]

Tertiary

File:Tertiary syphilis head.JPG

Model of a head of a person with tertiary (gummatous) syphilis, Musée de l'Homme, Paris

Tertiary syphilis may occur approximately 3 to 15 years after the initial infection and may be divided into three different forms: gummatous syphilis (15%), late neurosyphilis (6.5%), and cardiovascular syphilis (10%).^[3]^[25] Without treatment, a third of infected people develop tertiary disease.^[25] People with tertiary syphilis are not infectious.^[3]

Gummatous syphilis or late benign syphilis usually occurs 1 to 46 years after the initial infection, with an average of 15 years.^[3] This stage is characterized by the formation of chronic gummas, which are soft, tumor-like balls of inflammation which may vary considerably in size.^[3] They typically affect the skin, bone, and liver, but can occur anywhere.^[3]

Cardiovascular syphilis usually occurs 10–30 years after the initial infection.^[3] The most common complication is syphilitic aortitis, which may result in aortic aneurysm formation.^[3]

Neurosyphilis refers to an infection involving the central nervous system. Involvement of the central nervous system in syphilis (either asymptomatic or symptomatic) can occur at any stage of the infection.^[21] It may occur early, being either asymptomatic or in the form of syphilitic meningitis; or late as meningovascular syphilis, manifesting as general paresis or tabes dorsalis.^[3]

Meningovascular syphilis involves inflammation of the small and medium arteries of the central nervous system. It can present between 1–10 years after the initial infection. Meningovascular syphilis is characterized by stroke, cranial nerve palsies and spinal cord inflammation.^[30] Late symptomatic neurosyphilis can develop decades after the original infection and includes 2 types; general paresis and tabes dorsalis. General paresis presents with dementia, personality changes, delusions, seizures, psychosis and depression.^[30] Tabes dorsalis is characterized by gait instability, sharp pains in the trunk and limbs, impaired positional sensation of the limbs as well as having a positive Romberg's sign.^[30] Both tabes dorsalis and general paresis may present with Argyll Robertson pupil which are pupils that constrict when the person focuses on near objects (accommodation reflex) but do not constrict when exposed to bright light (pupillary reflex).

Congenital

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Congenital syphilis is that which is transmitted during pregnancy or during birth.^[4] Two-thirds of syphilitic infants are born without symptoms.^[4] Common symptoms that develop over the first couple of years of life include enlargement of the liver and spleen (70%), rash (70%), fever (40%), neurosyphilis (20%), and lung inflammation (20%).^[4] If untreated, late congenital syphilis may occur in 40%, including saddle nose deformation, Higouménakis' sign, saber shin, or Clutton's joints among others.^[4] Infection during pregnancy is also associated with miscarriage.^[31] The main dental defects seen in congenital syphilis are the peg-shaped, notched incisors known as Hutchinson's teeth and so-called mulberry molars (also known as Moon or Fournier molars), defective permanent molars with rounded, deformed crowns resembling a mulberry.^[32]

Cause

Bacteriology

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File:Treponema pallidum 01.png

Histopathology of Treponema pallidum bacteria using a modified Steiner silver stain, 1986

Treponema pallidum subspecies pallidum is a spiral-shaped, Gram-negative, highly mobile bacterium.^[11]^[22] Two other human diseases are caused by related Treponema pallidum subspecies, yaws (subspecies pertenue) and bejel (subspecies endemicum), and one further caused by the very closely related Treponema carateum, pinta.^[3]^[33] Unlike subspecies pallidum, they do not cause neurological disease.^[4] Humans are the only known natural reservoir for subspecies pallidum.^[34] It is unable to survive more than a few days without a host.^[22] This is due to its small genome (1.14 Mbp) failing to encode the metabolic pathways necessary to make most of its macronutrients.^[22] It has a slow doubling time of greater than 30 hours.^[22] The bacterium is known for its ability to evade the immune system and its invasiveness.^[35]

Transmission

Syphilis is transmitted primarily by sexual contact or during pregnancy from a mother to her baby; the bacterium is able to pass through intact mucous membranes or compromised skin.^[3]^[34] It is thus transmissible by kissing near a lesion, as well as manual, oral, vaginal, and anal sex.^[3]^[36]^[37] Approximately 30% to 60% of those exposed to primary or secondary syphilis will get the disease.^[25] Its infectivity is exemplified by the fact that an individual inoculated with only 57 organisms has a 50% chance of being infected.^[22] Most new cases in the United States (60%) occur in men who have sex with men; and in this population 20% of syphilis cases were due to oral sex alone.^[3]^[36] Syphilis can be transmitted by blood products, but the risk is low due to screening of donated blood in many countries.^[3] The risk of transmission from sharing needles appears to be limited.^[3]

It is not generally possible to contract syphilis through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.^[38] This is mainly because the bacteria die very quickly outside of the body, making transmission by objects extremely difficult.^[39]

Diagnosis

Poster for testing of syphilis, showing a man and a woman bowing their heads in shame

This Works Progress Administration poster (Template:Circa 1936) acknowledges the social stigma of syphilis, while urging those who possibly have the disease to be tested

File:Micrograph of secondary syphilis.jpg

Micrograph of secondary syphilis skin lesions. (A/B) H&E stain of SS lesions. (C/D) IHC staining reveals abundant bacteria embedded within a mixed cellular inflammatory infiltrate (shown in the red box) in the papillary dermis. The blue arrow points to a tissue histiocyte and the read arrows to two dermal lymphocytes^[40]

Syphilis is difficult to diagnose clinically during early infection.^[22] Confirmation is either via blood tests or direct visual inspection using dark field microscopy.^[3]^[41] Blood tests are more commonly used, as they are easier to perform.^[3] Diagnostic tests are unable to distinguish between the stages of the disease.^[42]

Blood tests

Blood tests are divided into nontreponemal and treponemal tests.^[22]

Nontreponemal tests are used initially and include venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) tests. False positives on the nontreponemal tests can occur with some viral infections, such as varicella (chickenpox) and measles. False positives can also occur with lymphoma, tuberculosis, malaria, endocarditis, connective tissue disease, and pregnancy.^[19]

Because of the possibility of false positives with nontreponemal tests, confirmation is required with a treponemal test, such as Treponema pallidum particle agglutination assay (TPHA) or fluorescent treponemal antibody absorption test (FTA-Abs).^[3] Treponemal antibody tests usually become positive two to five weeks after the initial infection^[22] and remain positive for many years.^[43] Neurosyphilis is diagnosed by finding high numbers of leukocytes (predominately lymphocytes) and high protein levels in the cerebrospinal fluid in the setting of a known syphilis infection.^[3]^[19]

Direct testing

Dark field microscopy of serous fluid from a chancre may be used to make an immediate diagnosis.^[22] Hospitals do not always have equipment or experienced staff members, and testing must be done within 10 minutes of acquiring the sample.^[22] Two other tests can be carried out on a sample from the chancre: direct fluorescent antibody (DFA) and polymerase chain reaction (PCR) tests.^[22] DFA uses antibodies tagged with fluorescein, which attach to specific syphilis proteins, while PCR uses techniques to detect the presence of specific syphilis genes.^[22] These tests are not as time-sensitive, as they do not require living bacteria to make the diagnosis.^[22]

Prevention

Vaccine

Template:As of, there is no vaccine effective for prevention.^[34] Several vaccines based on treponemal proteins reduce lesion development in an animal model but research continues.^[44]^[45]

Sex

Condom use reduces the likelihood of transmission during sex, but does not eliminate the risk.^[46] The Centers for Disease Control and Prevention (CDC) states, "Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected. However, a syphilis sore outside of the area covered by a latex condom can still allow transmission, so caution should be exercised even when using a condom."^[47]

Abstinence from intimate physical contact with an infected person is effective at reducing the transmission of syphilis. The CDC states, "The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected."^[47]

Congenital disease

File:Portrait of Mr. J. Kay, afflicted with a rodent disease. Unknown artist, c. 1820 CE. The Wellcome Collection, London.jpg

Portrait of a man affected with what is now believed to have been congenital syphilis, Template:Circa^[48]

Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected.^[49] The United States Preventive Services Task Force (USPSTF) strongly recommends universal screening of all pregnant women,^[50] while the World Health Organization (WHO) recommends all women be tested at their first antenatal visit and again in the third trimester.^[51]^[52] If they are positive, it is recommended their partners also be treated.^[51] Congenital syphilis is still common in the developing world, as many women do not receive antenatal care at all, and the antenatal care others receive does not include screening.^[49]^[53] It still occasionally occurs in the developed world, as those most likely to acquire syphilis are least likely to receive care during pregnancy.^[49] Several measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.^[51] Point-of-care testing to detect syphilis appeared to be reliable, although more research is needed to assess its effectiveness and into improving outcomes in mothers and babies.^[54]

Screening

The CDC recommends that sexually active men who have sex with men be tested at least yearly.^[55] The USPSTF also recommends screening among those at high risk.^[56]

Syphilis is a notifiable disease in many countries, including Canada,^[57] the European Union,^[58] and the United States.^[59] This means health care providers are required to notify public health authorities, which will then ideally provide partner notification to the person's partners.^[60] Physicians may also encourage patients to send their partners to seek care.^[61] Several strategies have been found to improve follow-up for STI testing, including email and text messaging of reminders for appointments.^[62]

Treatment

Historic use of mercury

As a form of chemotherapy, elemental mercury had been used to treat skin diseases in Europe as early as 1363.^[63] As syphilis spread, preparations of mercury were among the first medicines used to combat it. Mercury is in fact highly anti-microbial: by the 16th century it was sometimes found to be sufficient to halt development of the disease when applied to ulcers as an inunction or when inhaled as a suffumigation. It was also treated by ingestion of mercury compounds.^[64] Once the disease had gained a strong foothold, however, the amounts and forms of mercury necessary to control its development exceeded the human body's ability to tolerate it, and the treatment became worse and more lethal than the disease. Nevertheless, medically directed mercury poisoning became widespread through the 17th, 18th, and 19th centuries in Europe, North America, and India.^[65] Mercury salts such as mercury (II) chloride were still in prominent medical use as late as 1916, and considered effective and worthwhile treatments.^[66]

Early infections

The first-line treatment for uncomplicated syphilis (primary or secondary stages) remains a single dose of intramuscular benzathine benzylpenicillin.^[67] The bacterium is highly vulnerable to penicillin when treated early, and a treated individual is typically rendered non-infective in about 24 hours.^[68] Doxycycline and tetracycline are alternative choices for those allergic to penicillin; due to the risk of birth defects, these are not recommended for pregnant women.^[67] Resistance to macrolides, rifampicin, and clindamycin is often present.^[34] Ceftriaxone, a third-generation cephalosporin antibiotic, may be as effective as penicillin-based treatment.^[3] It is recommended that a treated person avoid sex until the sores are healed.^[38] In comparison to azithromycin for treatment in early infection, there is lack of strong evidence for superiority of azithromycin to benzathine penicillin G.^[69]

Late infections

For neurosyphilis, due to the poor penetration of benzathine penicillin into the central nervous system, those affected are given large doses of intravenous penicillin G for a minimum of 10 days.^[3]^[34] If a person is allergic to penicillin, ceftriaxone may be used or penicillin desensitization attempted.^[3] Other late presentations may be treated with once-weekly intramuscular benzathine penicillin for three weeks.^[3] Treatment at this stage solely limits further progression of the disease and has a limited effect on damage which has already occurred.^[3] Serologic cure can be measured when the non-treponemal titers decline by a factor of 4 or more in 6–12 months in early syphilis or 12–24 months in late syphilis.^[21]

Jarisch–Herxheimer reaction

File:Jarisch-Herxheimer reaction in patient (cropped).jpg

Jarisch–Herxheimer reaction in a person with syphilis and human immunodeficiency virus^[70]

One of the potential side effects of treatment is the Jarisch–Herxheimer reaction.^[3] It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscle pains, headache, and a fast heart rate.^[3] It results from the release of pro-inflammatory cytokines by the immune system in response to lipoproteins released from rupturing syphilis bacteria.^[71]

Pregnancy

Penicillin is an effective treatment for syphilis in pregnancy^[72] but there is no agreement on which dose or route of delivery is most effective.^[73]

Epidemiology

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File:Syphilis world map-Deaths per million persons-WHO2012.svg

Syphilis deaths per million persons in 2012 Template:Div col<templatestyles src="Legend/styles.css" />

0–0

1–1

2–3

4–10

11–19

20–28

29–57

58–138

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File:Syphilis world map - DALY - WHO2004.svg

Age-standardized disability adjusted life years from syphilis per 100,000 inhabitants in 2004^[74] <templatestyles src="Col-begin/styles.css"/>

no data

<35

35–70

70–105

105–140

140–175

175–210

210–245

245–280

280–315

315–350

350–500

>500

In 2012, about 0.5% of adults were infected with syphilis, with 6 million new cases.^[8] In 1999, it is believed to have infected 12 million additional people, with greater than 90% of cases in the developing world.^[34] It affects between 700,000 and 1.6 million pregnancies a year, resulting in miscarriages, stillbirths, and congenital syphilis.^[4] During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.^[9]^[10] In sub-Saharan Africa, syphilis contributes to approximately 20% of perinatal deaths.^[4] Rates are proportionally higher among intravenous drug users, those who are infected with HIV, and men who have sex with men.^[12]^[13]^[14] In the United States about 55,400 people are newly infected each year Template:As of.^[75] African Americans accounted for almost half of all cases in 2010.^[76] As of 2014, syphilis infections continue to increase in the United States.^[77]^[78] In the United States as of 2020, rates of syphilis have increased by more than threefold; in 2018 approximately 86% of all cases of syphilis in the United States were in men.^[21] In 2021, preliminary CDC data illustrated that 2,677 cases of congenital syphilis were found in the population of 332 million in the United States.^[79]

Syphilis was very common in Europe during the 18th and 19th centuries.^[11] Flaubert found it universal among 19th-century Egyptian prostitutes.^[80] In the developed world during the early 20th century, infections declined rapidly with the widespread use of antibiotics, until the 1980s and 1990s.^[11] Since 2000, rates of syphilis have been increasing in the US, Canada, the UK, Australia and Europe, primarily among men who have sex with men.^[34] Rates of syphilis among US women have remained stable during this time, while rates among UK women have increased, but at a rate less than that of men.^[81] Increased rates among heterosexuals have occurred in China and Russia since the 1990s.^[34] This has been attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and decreasing use of barrier protection.^[34]^[81]^[82]

Left untreated, it has a mortality rate of 8% to 58%, with a greater death rate among males.^[3] The symptoms of syphilis have become less severe over the 19th and 20th centuries, in part due to widespread availability of effective treatment, and partly due to virulence of the bacteria.^[23] With early treatment, few complications result.^[22] Syphilis increases the risk of HIV transmission by two to five times, and coinfection is common (30–60% in some urban centers).^[3]^[34] In 2015, Cuba became the first country to eliminate mother-to-child transmission of syphilis.^[83]

History

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Origin, spread and discovery

File:Rembrandt Harmensz. van Rijn 095.jpg

Portrait of Gerard de Lairesse by Rembrandt van Rijn, circa 1665–67, oil on canvas. De Lairesse, himself a painter and art theorist, had congenital syphilis that deformed his face and eventually blinded him^[84]

Paleopathologists have known for decades that syphilis was present in the Americas before European contact.^[85]^[86] The situation in Afro-Eurasia has been murkier and caused considerable debate.^[87] According to the Columbian theory, syphilis was brought to Spain by the men who sailed with Christopher Columbus in 1492 and spread from there, with a serious epidemic in Naples beginning as early as 1495. Contemporaries believed the disease sprang from American roots, and in the 16th century physicians wrote extensively about the new disease inflicted on them by the returning explorers.^[88]

Most evidence supports the Columbian origin hypothesis.^[89] However, beginning in the 1960s, examples of probable treponematosis—the parent disease of syphilis, bejel, and yaws—in skeletal remains shifted the opinion of some towards a "pre-Columbian" origin.^[90]^[91] A 2024 study published in Nature supported an emergence postdating human occupation in the Americas.^[92]

When living conditions changed with urbanization, elite social groups began to practice basic hygiene and started to separate themselves from other social tiers. Consequently, treponematosis was driven out of the age group in which it had become endemic. It then began to appear in adults as syphilis. Because they had never been exposed as children, they were not able to fend off serious illness. Spreading the disease via sexual contact also led to victims being infected with a massive bacterial load from open sores on the genitalia. Adults in higher socioeconomic groups then became very sick with painful and debilitating symptoms lasting for decades. Often, they died of the disease, as did their children who were infected with congenital syphilis. The difference between rural and urban populations was first noted by Ellis Herndon Hudson, a clinician who published extensively about the prevalence of treponematosis, including syphilis, in times past.^[93] The importance of bacterial load was first noted by the physician Ernest Grin in 1952 in his study of syphilis in Bosnia.^[94]

The most compelling evidence for the validity of the pre-Columbian hypothesis is the presence of syphilitic-like damage to bones and teeth in medieval skeletal remains. While the absolute number of cases is not large, new ones are continually discovered, most recently in 2015.^[95] At least fifteen cases of acquired treponematosis based on evidence from bones, and six examples of congenital treponematosis based on evidence from teeth, are now widely accepted. In several of the twenty-one cases the evidence may also indicate syphilis.^[96]

File:Medieval illumination of Christ being tortured.jpg

A healthy man and a diseased man torture Christ before his crucifixion. From a French book of hours, Template:Circa

In 2020, a group of leading paleopathologists concluded that enough evidence had been collected to prove that treponemal disease, almost certainly including syphilis, had existed in Europe prior to the voyages of Columbus.^[97] There is an outstanding issue, however. Damaged teeth and bones may seem to hold proof of pre-Columbian syphilis, but there is a possibility that they point to an endemic form of treponemal disease instead. As syphilis, bejel, and yaws vary considerably in mortality rates and the level of human disease they elicit, it is important to know which one is under discussion in any given case, but it remains difficult for paleopathologists to distinguish among them. (The fourth of the treponemal diseases is pinta, a skin disease and therefore unrecoverable through paleopathology.) Ancient DNA (aDNA) holds the answer, because just as only aDNA suffices to distinguish between syphilis and other diseases that produce similar symptoms in the body, it alone can differentiate spirochetes that are 99.8 percent identical with absolute accuracy.^[98] Progress on uncovering the historical extent of syndromes through aDNA remains slow, however, because the bacterium responsible for treponematosis is rare in skeletal remains and fragile, making it notoriously difficult to recover and analyse. Precise dating to the medieval period is not yet possible but work by Kettu Majander et al. uncovering the presence of several different kinds of treponematosis at the beginning of the early modern period argues against its recent introduction from elsewhere. Therefore, they argue, treponematosis—possibly including syphilis—almost certainly existed in medieval Europe.^[99]

Despite significant progress in tracing the presence of syphilis in past historic periods, definitive findings from paleopathology and aDNA studies are still lacking for the medieval period. Evidence from art is therefore helpful in settling the issue. Research by Marylynn Salmon has demonstrated that deformities in medieval subjects can be identified by comparing them to those of modern victims of syphilis in medical drawings and photographs.^[100] One of the most typical deformities, for example, is a collapsed nasal bridge called saddle nose. Salmon discovered that it appeared often in medieval illuminations, especially among the men tormenting Christ in scenes of the crucifixion. The association of saddle nose with evil is an indication that the artists were thinking of syphilis, which is typically transmitted through sexual intercourse with promiscuous partners, a mortal sin in medieval times.

It remains mysterious why the authors of medieval medical treatises so uniformly refrained from describing syphilis or commenting on its existence in the population. Many may have confused it with other diseases such as leprosy (Hansen's disease) or elephantiasis. The great variety of symptoms of treponematosis, the different ages at which the various diseases appear, and its widely divergent outcomes depending on climate and culture, would have added greatly to the confusion of medical practitioners, as indeed they did right down to the middle of the 20th century. In addition, evidence indicates that some writers on disease feared the political implications of discussing a condition more fatal to elites than to commoners. Historian Jon Arrizabalaga has investigated this question for Castile with startling results revealing an effort to hide its association with elites.^[101]

The first written records of an outbreak of syphilis in Europe occurred in 1495 in Naples, Italy, during a French invasion (Italian War of 1494–1495).^[11]^[42] Since it was claimed to have been spread by French troops, it was initially called the "French disease" by the people of Naples.^[102] The disease reached London in 1497 and was recorded at St Bartholomew's Hospital as infecting 10 out of the 20 patients.^[103]Template:Fcn In 1530, the pastoral name "syphilis" (the name of a character) was first used by the Italian physician and poet Girolamo Fracastoro as the title of his Latin poem in dactylic hexameter, Script error: No such module "Lang". (Syphilis or The French Disease), describing the ravages of the disease in Italy.^[104]^[105] In Great Britain it was also called the "Great Pox".^[106]^[107]

In the 16th through 19th centuries, syphilis was one of the largest public health burdens in prevalence, symptoms, and disability,^[108]Template:Rp^[109] although records of its true prevalence were generally not kept because of the fearsome and sordid status of sexually transmitted infections in those centuries.^[108]Template:Rp According to a 2020 study, more than 20% of individuals in the age range 15–34 years in late 18th-century London were treated for syphilis.^[110] At the time the causative agent was unknown but it was well known that it was spread sexually and also often from mother to child. Its association with sex, especially sexual promiscuity and prostitution, made it an object of fear and revulsion and a taboo. The magnitude of its morbidity and mortality in those centuries reflected that, unlike today, there was no adequate understanding of its pathogenesis and no truly effective treatments. Its damage was caused not so much by great sickness or death early in the course of the disease but rather by its gruesome effects decades after infection as it progressed to neurosyphilis with tabes dorsalis. Mercury compounds and isolation were commonly used, with treatments often worse than the disease.^[106]

The causative organism, Treponema pallidum, was first identified by Fritz Schaudinn and Erich Hoffmann, in 1905.^[111] The first effective treatment for syphilis was arsphenamine, discovered by Sahachiro Hata in 1909, during a survey of hundreds of newly synthesized organic arsenical compounds led by Paul Ehrlich. It was manufactured and marketed from 1910 under the trade name Salvarsan by Hoechst AG.^[112] This organoarsenic compound was the first modern chemotherapeutic agent.

During the 20th century, as both microbiology and pharmacology advanced greatly, syphilis, like many other infectious diseases, became more of a manageable burden than a scary and disfiguring mystery, at least in developed countries among those people who could afford to pay for timely diagnosis and treatment. Penicillin was discovered in 1928, and effectiveness of treatment with penicillin was confirmed in trials in 1943,^[106] at which time it became the main treatment.^[113]

Many famous historical figures, including Franz Schubert, Arthur Schopenhauer, Édouard Manet,^[11] Charles Baudelaire,^[114] and Guy de Maupassant are believed to have had the disease.^[115] Friedrich Nietzsche was long believed to have gone mad as a result of tertiary syphilis, but that diagnosis has recently come into question.^[116]

Arts and literature

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File:400Behandlung der Syphilis.jpg

An early medical illustration of people with syphilis, Vienna, 1498

The earliest known depiction of an individual with syphilis is Albrecht Dürer's Syphilitic Man (1496), a woodcut believed to represent a Landsknecht, a Northern European mercenary.^[117] The myth of the Script error: No such module "Lang". or "poison women" of the 19th century is believed to be partly derived from the devastation of syphilis, with classic examples in literature including John Keats' Script error: No such module "Lang"..^[118]^[119]

The Flemish artist Stradanus designed a print called Preparation and Use of Guayaco for Treating Syphilis, a scene of a wealthy man receiving treatment for syphilis with the tropical wood guaiacum sometime around 1590.^[120]

Tuskegee and Guatemala studies

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File:Stop syphilis LCCN98509573.jpg

A Work Projects Administration poster about syphilis c. 1940

The "Tuskegee Study of Untreated Syphilis in the Negro Male" was an infamous, unethical and racist clinical study conducted between 1932 and 1972 by the U.S. Public Health Service.^[121]^[122] Whereas the purpose of this study was to observe the natural history of untreated syphilis, the African-American men in the study were told they were receiving free treatment for "bad blood" from the United States government.^[123]

The Public Health Service started working on this study in 1932 in collaboration with Tuskegee University, a historically black college in Alabama. Researchers enrolled 600 poor, African American sharecroppers from Macon County, Alabama in the study. Of these men, 399 had contracted syphilis before the study began, and 201 did not have the disease.^[122] Medical care, hot meals and free burial insurance were given to those who participated. The men were told that the study would last six months, but in the end, it continued for 40 years.^[122] After funding for treatment was lost, the study was continued without informing the men that they were only being studied and would not be treated. Facing insufficient participation, the Macon County Health Department nevertheless wrote to subjects to offer them a "last chance" to get a special "treatment", which was not a treatment at all, but a spinal tap administered exclusively for diagnostic purposes.^[121] None of the men infected were ever told that they had the disease, and none were treated with penicillin even after the antibiotic had been proven to successfully treat syphilis. According to the Centers for Disease Control, the men were told they were being treated for "bad blood"—a colloquialism describing various conditions such as fatigue, anemia and syphilis—which was a leading cause of death among southern African American men.^[122]

File:De ontdekking van Guaiacum als middel tegen syfilis, anoniem, Museum Plantin-Moretus, PK OPB 0186 007.jpg

Preparation and Use of Guayaco for Treating Syphilis, after Stradanus, 1590

The 40-year study became a textbook example of criminally negligent medical ethics because researchers had knowingly withheld treatment with penicillin and because the subjects had been misled concerning the purposes of the study. The revelation in 1972 of these study failures by a whistleblower, Peter Buxtun, led to major changes in U.S. law and regulation on the protection of participants in clinical studies. Now studies require informed consent,^[124] communication of diagnosis, and accurate reporting of test results.^[125]

Similar experiments were carried out in Guatemala from 1946 to 1948. It was done during the administration of American President Harry S. Truman and Guatemalan President Juan José Arévalo with the cooperation of some Guatemalan health ministries and officials.^[126] Doctors infected soldiers, prostitutes, prisoners and mental patients with syphilis and other sexually transmitted infections, without the informed consent of the subjects and treated most subjects with antibiotics. The experiment resulted in at least 83 deaths.^[127]^[128] In October 2010, the U.S. formally apologized to Guatemala for the ethical violations that took place. Secretary of State Hillary Clinton and Health and Human Services Secretary Kathleen Sebelius stated "Although these events occurred more than 64 years ago, we are outraged that such reprehensible research could have occurred under the guise of public health. We deeply regret that it happened, and we apologize to all the individuals who were affected by such abhorrent research practices."^[129] The experiments were led by physician John Charles Cutler who also participated in the late stages of the Tuskegee syphilis experiment.^[130]

Names

Syphilis was first called Script error: No such module "Lang". or the "great pox" by the French. Other historical names have included "button scurvy", sibbens, frenga, and dichuchwa, among others.^[131]^[132] Since it was a disgraceful disease, the disease was known in several countries by the name of their neighbouring, often hostile country.^[113] The English, the Germans, and the Italians called it "the French disease", while the French referred to it as the "Neapolitan disease". The Dutch called it the "Spanish/Castilian disease".^[113] To the Turks it was known as the "Christian disease", whilst in India, the Hindus and Muslims named the disease after each other.^[113]

References

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External links

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↑ Baker, B. J. and Armelagos, G. J., (1988) "The origin and antiquity of syphilis: Paleopathological diagnosis and interpretation". Current Anthropology, 29, 703–738. https://doi.org/10.1086/203691. Powell, M. L. & Cook, D. C. (2005) The Myth of Syphilis: The natural history of treponematosis in North America. Gainesville, FL: University Press of Florida. Williams, H. (1932) "The origin and antiquity of syphilis: The evidence from diseased bones, a review, with some new material from America". Archives of Pathology, 13: 779–814, 931–983.1932).
↑ Dutour, O., et al. (Eds.). (1994). L'origine de la syphilis in Europe: avant ou après 1493? Paris, France: Éditions Errance. Baker, B. J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". Yearbook of Physical Anthropology 171: 5–41. doi: 10.1002/ajpa.23988. Harper, K. N., Zuckerman, M. K., Harper, M. L., Kingston, J. D., Armelagos, G. J. (2011) "The origin and antiquity of syphilis revisited: An appraisal of Old World Pre-Columbian evidence of treponemal infections". Yearbook of Physical Anthropology, 54: 99–133. https://doi.org/10.1002/ajpa.21613.
↑ For an introduction to this literature see Quétel, C. (1990). History of Syphilis. Baltimore, MD: The Johns Hopkins University Press.
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↑ Early work includes Henneberg, M., & Henneberg, R. J. (1994), "Treponematosis in an ancient Greek colony of Metaponto, southern Italy, 580-250 BCE" and Roberts, C. A. (1994), "Treponematosis in Gloucester, England: A theoretical and practical approach to the Pre-Columbian theory". Both in O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: avant ou après 1493? (pp. 92-98; 101–108). Paris, France: Éditions Errance.
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↑ Hudson, E. H. (1946). "A unitarian view of treponematosis". American Journal of Tropical Medicine and Hygiene, 26 (1946), 135–139. https://doi.org/10.4269/ajtmh.1946.s1-26.135; "The treponematoses—or treponematosis?" The British Journal of Venereal Diseases, 34 (1958), 22–23; "Historical approach to the terminology of syphilis". Archives of Dermatology, 84 (1961), 545–562; "Treponematosis and man's social evolution". American Anthropologist, 67(4), 885–901. doi:10.1001/archderm.1961.01580160009002. On status see also Marylynn Salmon, Medieval Syphilis and Treponemal Disease (Leeds: Arc Humanities Press), 8, 30-33.
↑ Grin, E. I. (1952) "Endemic Treponematosis in Bosnia: Clinical and epidemiological observations on a successful mass-treatment campaign". Bulletin of the World Health Organization, 7: 11-25.
↑ Walker, D., Powers, N., Connell, B., & Redfern, R. (2015). "Evidence of skeletal treponematosis from the Medieval burial ground of St. Mary Spital, London, and implications for the origins of the disease in Europe". American Journal of Physical Anthropology, 156, 90–101. https://doi.org/10.1002/ajpa.22630 and Gaul, J.S., Grossschmidt, K., Budenbauer, C., & Kanz, Fabian (2015). "A probable case of congenital syphilis from pre-Columbian Austria". Anthropologischer Anzeiger, 72, 451–472. DOI: 10.1127/anthranz/2015/0504.
↑ They include Henneberg, M., & Henneberg, R. J. (1994). "Treponematosis in an ancient Greek colony of Metaponto, southern Italy, 580-250 BCE". In O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: Avant ou après 1493? (pp. 92–98). Paris, France: Éditions Errance. Stirland, Ann. "Evidence for Pre-Columbian Treponematosis in Europe". In Dutour, O., Pálfi, G., Bérato, J., & Brun, J. -P. (Eds.). (1994). L'origine de la syphilis in Europe: avant ou après 1493? Paris, France: Éditions Errance, and Criminals and Paupers: The Graveyard of St. Margaret Fyebriggate in combusto, Norwich. With Contributions from Brian Ayers and Jayne Brown. East Anglian Archaeology 129. Dereham: Historic Environment, Norfolk Museums and Archaeology Service, 2009. Erdal, Y. S. (2006). "A pre-Columbian case of congenital syphilis from Anatolia (Nicaea, 13th century AD)". International Journal of Osteoarchaeology, 16, 16–33. https://doi.org/10.1002/oa.802. Cole G. and T. Waldron, "Apple Down 152: a putative case of syphilis from sixth century AD Anglo-Saxon England". American Journal of Physical Anthropology 2011 Jan;144(1):72-9. doi: 10.1002/ajpa.21371. Epub 2010 Aug 18. PMID 20721939. Roberts, C. A. (1994). "Treponematosis in Gloucester, England: A theoretical and practical approach to the Pre-Columbian theory". In O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: avant ou après 1493? (pp. 101–108). Paris, France: Éditions Errance.
↑ Baker, B.J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". Yearbook of Physical Anthropology 171: 5–41. doi: 10.1002/ajpa.23988.
↑ Fraser, C. M., Norris, S. J., Weinstock, G. M., White, O., Sutton, G. G., Dodson, R., ... Venter, J. C. (1998). "Complete genome sequence of Treponema pallidum, the syphilis spirochete". Science, 281(5375), 375–388. https://doi.org/10.1371/journal.pntd.0001832. Čejková, D., Zobaníková, M., Chen, L., Pospíšilová, P., Strouhal, M., Qin, X., ... Šmajs, D. (2012). "Whole genome sequences of three Treponema pallidum ssp. pertenue strains: yaws and syphilis treponemes differ in less than 0.2% of the genome sequence". PLoS Neglected Tropical Diseases, 6(1), e1471. doi: 10.1371/journal.pone.0015713. Mikalová, L., Strouhal, M., Čejková, D., Zobaníková, M., Pospíšilová, P., Norris, S. J., ... Šmajs, D. (2010). "Genome analysis of Treponema pallidum subsp. pallidum and subsp. pertenue strains: Most of the genetic differences are localized in six regions". PLoS ONE, 5, e15713. doi.org/10.1371/journal.pone.0015713. Štaudová, B., Strouhal, M., Zobaníková, M., Čejková, D., Fulton, L. L., Chen, L., ... Šmajs, D. (2014). "Whole genome sequence of the Treponema pallidum subsp. endemicum strain Bosnia A: The genome is related to yaws treponemes but contains few loci similar to syphilis treponemes". PLoS Neglected Tropical Diseases, 8(11), e3261. https://doi.org/10.1371/journal.pntd.0003261.
↑ Majander, K., Pfrengle S., Kocher, A., ..., Kühnert, J. K., Schuenemann, V. J. (2020), "Ancient Bacterial Genomes Reveal a High Diversity of Treponema pallidum Strains in Early Modern Europe". Current Biology 30, 3788–3803. Elsevier Inc. doi: 10.1016/j.cub.2020.07.058.
↑ See her Medieval Syphilis and Treponemal Disease (Leeds: Arc Humanities Press, 2022), 61-79.
↑ Arrizabalaga, Jon. "The Changing Identity of the French Pox in Early Renaissance Castile". In Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe, edited by Florence Eliza Glaze and Brian K. Nance, 397–417. Florence: SISMEL, 2011.
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[86] Baker, B. J. and Armelagos, G. J., (1988) "The origin and antiquity of syphilis: Paleopathological diagnosis and interpretation". Current Anthropology, 29, 703–738. https://doi.org/10.1086/203691. Powell, M. L. & Cook, D. C. (2005) The Myth of Syphilis: The natural history of treponematosis in North America. Gainesville, FL: University Press of Florida. Williams, H. (1932) "The origin and antiquity of syphilis: The evidence from diseased bones, a review, with some new material from America". Archives of Pathology, 13: 779–814, 931–983.1932).

[87] Dutour, O., et al. (Eds.). (1994). L'origine de la syphilis in Europe: avant ou après 1493? Paris, France: Éditions Errance. Baker, B. J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". Yearbook of Physical Anthropology 171: 5–41. doi: 10.1002/ajpa.23988. Harper, K. N., Zuckerman, M. K., Harper, M. L., Kingston, J. D., Armelagos, G. J. (2011) "The origin and antiquity of syphilis revisited: An appraisal of Old World Pre-Columbian evidence of treponemal infections". Yearbook of Physical Anthropology, 54: 99–133. https://doi.org/10.1002/ajpa.21613.

[88] For an introduction to this literature see Quétel, C. (1990). History of Syphilis. Baltimore, MD: The Johns Hopkins University Press.

[89] Script error: No such module "citation/CS1".

[90] Early work includes Henneberg, M., & Henneberg, R. J. (1994), "Treponematosis in an ancient Greek colony of Metaponto, southern Italy, 580-250 BCE" and Roberts, C. A. (1994), "Treponematosis in Gloucester, England: A theoretical and practical approach to the Pre-Columbian theory". Both in O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: avant ou après 1493? (pp. 92-98; 101–108). Paris, France: Éditions Errance.

[91] Script error: No such module "citation/CS1".

[92] Script error: No such module "Citation/CS1".

[93] Hudson, E. H. (1946). "A unitarian view of treponematosis". American Journal of Tropical Medicine and Hygiene, 26 (1946), 135–139. https://doi.org/10.4269/ajtmh.1946.s1-26.135; "The treponematoses—or treponematosis?" The British Journal of Venereal Diseases, 34 (1958), 22–23; "Historical approach to the terminology of syphilis". Archives of Dermatology, 84 (1961), 545–562; "Treponematosis and man's social evolution". American Anthropologist, 67(4), 885–901. doi:10.1001/archderm.1961.01580160009002. On status see also Marylynn Salmon, Medieval Syphilis and Treponemal Disease (Leeds: Arc Humanities Press), 8, 30-33.

[94] Grin, E. I. (1952) "Endemic Treponematosis in Bosnia: Clinical and epidemiological observations on a successful mass-treatment campaign". Bulletin of the World Health Organization, 7: 11-25.

[95] Walker, D., Powers, N., Connell, B., & Redfern, R. (2015). "Evidence of skeletal treponematosis from the Medieval burial ground of St. Mary Spital, London, and implications for the origins of the disease in Europe". American Journal of Physical Anthropology, 156, 90–101. https://doi.org/10.1002/ajpa.22630 and Gaul, J.S., Grossschmidt, K., Budenbauer, C., & Kanz, Fabian (2015). "A probable case of congenital syphilis from pre-Columbian Austria". Anthropologischer Anzeiger, 72, 451–472. DOI: 10.1127/anthranz/2015/0504.

[96] They include Henneberg, M., & Henneberg, R. J. (1994). "Treponematosis in an ancient Greek colony of Metaponto, southern Italy, 580-250 BCE". In O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: Avant ou après 1493? (pp. 92–98). Paris, France: Éditions Errance. Stirland, Ann. "Evidence for Pre-Columbian Treponematosis in Europe". In Dutour, O., Pálfi, G., Bérato, J., & Brun, J. -P. (Eds.). (1994). L'origine de la syphilis in Europe: avant ou après 1493? Paris, France: Éditions Errance, and Criminals and Paupers: The Graveyard of St. Margaret Fyebriggate in combusto, Norwich. With Contributions from Brian Ayers and Jayne Brown. East Anglian Archaeology 129. Dereham: Historic Environment, Norfolk Museums and Archaeology Service, 2009. Erdal, Y. S. (2006). "A pre-Columbian case of congenital syphilis from Anatolia (Nicaea, 13th century AD)". International Journal of Osteoarchaeology, 16, 16–33. https://doi.org/10.1002/oa.802. Cole G. and T. Waldron, "Apple Down 152: a putative case of syphilis from sixth century AD Anglo-Saxon England". American Journal of Physical Anthropology 2011 Jan;144(1):72-9. doi: 10.1002/ajpa.21371. Epub 2010 Aug 18. PMID 20721939. Roberts, C. A. (1994). "Treponematosis in Gloucester, England: A theoretical and practical approach to the Pre-Columbian theory". In O. Dutour, et al. (Eds.), L'origine de la syphilis in Europe: avant ou après 1493? (pp. 101–108). Paris, France: Éditions Errance.

[97] Baker, B.J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". Yearbook of Physical Anthropology 171: 5–41. doi: 10.1002/ajpa.23988.

[98] Fraser, C. M., Norris, S. J., Weinstock, G. M., White, O., Sutton, G. G., Dodson, R., ... Venter, J. C. (1998). "Complete genome sequence of Treponema pallidum, the syphilis spirochete". Science, 281(5375), 375–388. https://doi.org/10.1371/journal.pntd.0001832. Čejková, D., Zobaníková, M., Chen, L., Pospíšilová, P., Strouhal, M., Qin, X., ... Šmajs, D. (2012). "Whole genome sequences of three Treponema pallidum ssp. pertenue strains: yaws and syphilis treponemes differ in less than 0.2% of the genome sequence". PLoS Neglected Tropical Diseases, 6(1), e1471. doi: 10.1371/journal.pone.0015713. Mikalová, L., Strouhal, M., Čejková, D., Zobaníková, M., Pospíšilová, P., Norris, S. J., ... Šmajs, D. (2010). "Genome analysis of Treponema pallidum subsp. pallidum and subsp. pertenue strains: Most of the genetic differences are localized in six regions". PLoS ONE, 5, e15713. doi.org/10.1371/journal.pone.0015713. Štaudová, B., Strouhal, M., Zobaníková, M., Čejková, D., Fulton, L. L., Chen, L., ... Šmajs, D. (2014). "Whole genome sequence of the Treponema pallidum subsp. endemicum strain Bosnia A: The genome is related to yaws treponemes but contains few loci similar to syphilis treponemes". PLoS Neglected Tropical Diseases, 8(11), e3261. https://doi.org/10.1371/journal.pntd.0003261.

[99] Majander, K., Pfrengle S., Kocher, A., ..., Kühnert, J. K., Schuenemann, V. J. (2020), "Ancient Bacterial Genomes Reveal a High Diversity of Treponema pallidum Strains in Early Modern Europe". Current Biology 30, 3788–3803. Elsevier Inc. doi: 10.1016/j.cub.2020.07.058.

[100] See her Medieval Syphilis and Treponemal Disease (Leeds: Arc Humanities Press, 2022), 61-79.

[101] Arrizabalaga, Jon. "The Changing Identity of the French Pox in Early Renaissance Castile". In Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe, edited by Florence Eliza Glaze and Brian K. Nance, 397–417. Florence: SISMEL, 2011.

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[103] Hidden Killers of the Tudor Home: The Horrors of Tudor Dentistry etc

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@@ Line 1: / Line 1: @@
 {{Short description|Sexually transmitted infection}}
-{{Distinguish|Sisyphus}}
+{{Good article}}
+{{Pp|small=yes}}
 {{Use dmy dates|date=June 2024}}
 {{cs1 config |name-list-style=vanc |display-authors=6}}
-{{pp|small=yes}}
-{{good article}}
 {{Infobox medical condition (new)
 | name = Syphilis
@@ Line 15: / Line 14: @@
 | onset =
 | duration =
-| causes = ''Treponema pallidum'', usually spread by sex<ref name=Goldman2020/>
+| causes = ''[[Treponema pallidum]]'', usually spread by [[sexual intercourse]]<ref name=Goldman2020/>
 | risks =
 | diagnosis = [[serological testing|Blood tests]], [[dark field microscopy]] of infected fluid<ref name=CDC2015Fact/><ref name=Kent08/>
@@ Line 28: / Line 27: @@
 '''Syphilis''' ({{IPAc-en|ˈ|s|ɪ|f|ə|l|ɪ|s|,_|ˈ|s|ɪ|f|ɪ|l|ɪ|s}}) is a [[sexually transmitted infection]] caused by the [[bacterium]] ''[[Treponema pallidum]]'' [[subspecies]] ''pallidum''.<ref name=Goldman2020>{{cite book |last1=Ghanem|first1=Khalil G.|last2=Hook|first2=Edward W.|editor1-last=Goldman |editor1-first=Lee |editor2-last=Schafer |editor2-first=Andrew I. |title=[[Goldman-Cecil Medicine]] |date=2020 |publisher=Elsevier |location=Philadelphia|isbn=978-0-323-55087-1 |pages=1983–1989|edition=26th|volume=2 |chapter-url=https://books.google.com/books?id=7pKqDwAAQBAJ&pg=PA1983 |chapter=303. Syphilis}}</ref> The signs and symptoms depend on the stage it presents: primary, secondary, [[latent syphilis|latent]] or tertiary.<ref name=Goldman2020/><ref name=CDC2015Fact/> The primary stage classically presents with a single [[chancre]] (a firm, painless, non-itchy [[Ulcer_(dermatology)|skin ulceration]] usually between 1&nbsp;cm and 2&nbsp;cm in diameter), though there may be multiple sores.<ref name=CDC2015Fact/> In secondary syphilis, a diffuse [[rash]] occurs, which frequently involves the palms of the hands and soles of the feet.<ref name=CDC2015Fact/> There may also be sores in the mouth or vagina.<ref name=CDC2015Fact/> Latent syphilis has no symptoms and can last years.<ref name=CDC2015Fact/> In tertiary syphilis, there are [[Gumma (pathology)|gummas]] (soft, non-cancerous growths), neurological problems, or heart symptoms.<ref name=Kent08>{{cite journal |vauthors=Kent ME, Romanelli F |title=Reexamining syphilis: an update on epidemiology, clinical manifestations, and management |journal=Annals of Pharmacotherapy |volume=42 |issue=2 |pages=226–36 |date=February 2008 |pmid=18212261 |doi=10.1345/aph.1K086 |s2cid=23899851}}</ref> Syphilis has been known as "[[The Great Imitator|the great imitator]]", because it may cause symptoms similar to many other diseases.<ref name=CDC2015Fact>{{cite web |title=Syphilis – CDC Fact Sheet (Detailed) |url=https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |website=CDC |access-date=3 February 2016 |date=2 November 2015|url-status=live |archive-url=https://web.archive.org/web/20160206003059/http://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |archive-date=6 February 2016}}</ref><ref name=Kent08/>
-Syphilis is most commonly spread through [[human sexual activity|sexual activity]].<ref name=CDC2015Fact/> It may also be [[Vertical transmission|transmitted from mother to baby]] during pregnancy or at birth, resulting in [[congenital syphilis]].<ref name=CDC2015Fact/><ref name=Wood09>{{cite journal |author=Woods, CR |title=Congenital syphilis-persisting pestilence |journal=The Pediatric Infectious Disease Journal |volume=28 |issue=6 |pages=536–537 |date=June 2009 |pmid=19483520|doi=10.1097/INF.0b013e3181ac8a69}}</ref> Other diseases caused by ''[[Treponema]]'' bacteria include [[yaws]] (''[[Treponema pallidum|T. pallidum]]'' subspecies ''pertenue''), [[Pinta (disease)|pinta]] (''[[Treponema carateum|T. carateum]]''), and [[nonvenereal endemic syphilis]] (''T. pallidum'' subspecies ''endemicum'').<ref name=Kent08/> These three diseases are not typically sexually transmitted.<ref>{{cite web |title=Pinta |url=https://rarediseases.org/rare-diseases/pinta/ |website=NORD |access-date=13 April 2018 |archive-date=16 August 2018 |archive-url=https://web.archive.org/web/20180816031132/https://rarediseases.org/rare-diseases/pinta/ |url-status=live}}</ref> Diagnosis is usually made by using [[serological testing|blood tests]]; the bacteria can also be detected using [[dark field microscopy]].<ref name=CDC2015Fact/> The [[Centers for Disease Control and Prevention]] (U.S.) recommends for all pregnant women to be tested.<ref name=CDC2015Fact/>
+Syphilis is most commonly spread through [[human sexual activity|sexual activity]].<ref name=CDC2015Fact/> It may also be transmitted from mother to baby during pregnancy or at birth, resulting in [[congenital syphilis]].<ref name=CDC2015Fact/><ref name=Wood09>{{cite journal |author=Woods, CR |title=Congenital syphilis-persisting pestilence |journal=The Pediatric Infectious Disease Journal |volume=28 |issue=6 |pages=536–537 |date=June 2009 |pmid=19483520|doi=10.1097/INF.0b013e3181ac8a69}}</ref> Other diseases caused by ''[[Treponema]]'' bacteria include [[yaws]] (''[[Treponema pallidum|T. pallidum]]'' subspecies ''pertenue''), [[Pinta (disease)|pinta]] (''[[Treponema carateum|T. carateum]]''), and [[nonvenereal endemic syphilis]] (''T. pallidum'' subspecies ''endemicum'').<ref name=Kent08/> These three diseases are not typically sexually transmitted.<ref>{{cite web |title=Pinta |url=https://rarediseases.org/rare-diseases/pinta/ |website=NORD |access-date=13 April 2018 |archive-date=16 August 2018 |archive-url=https://web.archive.org/web/20180816031132/https://rarediseases.org/rare-diseases/pinta/ |url-status=live}}</ref> Diagnosis is usually made by using [[serological testing|blood tests]]; the bacteria can also be detected using [[dark field microscopy]].<ref name=CDC2015Fact/> The [[Centers for Disease Control and Prevention]] (U.S.) recommends for all pregnant women to be tested.<ref name=CDC2015Fact/>
 The risk of sexual transmission of syphilis can be reduced by using a [[latex]] or [[polyurethane]] [[condom]].<ref name=CDC2015Fact/> Syphilis can be effectively treated with [[antibiotics]].<ref name=CDC2015Tx>{{cite web|title=Syphilis|url=https://www.cdc.gov/std/tg2015/syphilis.htm|website=CDC|access-date=3 February 2016|date=4 June 2015|url-status=live|archive-url=https://web.archive.org/web/20160221200405/http://www.cdc.gov/std/tg2015/syphilis.htm|archive-date=21 February 2016}}</ref> The preferred antibiotic for most cases is [[benzathine benzylpenicillin]] [[Intramuscular injection|injected into a muscle]].<ref name=CDC2015Tx/> In those who have a severe [[penicillin allergy]], [[doxycycline]] or [[tetracycline]] may be used.<ref name=CDC2015Tx/> In those with [[neurosyphilis]], [[intravenous]] [[benzylpenicillin]] or [[ceftriaxone]] is recommended.<ref name=CDC2015Tx/> During treatment, people may develop fever, headache, and [[myalgia|muscle pains]], a reaction known as [[Jarisch–Herxheimer reaction|Jarisch–Herxheimer]].<ref name=CDC2015Tx/>
-In 2015, about 45.4&nbsp;million people had syphilis infections,<ref name=GBD2015Pre>{{cite journal|vauthors=((GBD 2015 Maternal Mortality Collaborators)) |title=Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 |journal=Lancet|date=October 2016 |volume=388 |issue=10053 |pages=1545–1602 |pmid=27733282 |doi=10.1016/S0140-6736(16)31678-6 |pmc=5055577}}</ref> of which six million were new cases.<ref name=New2015>{{cite journal |last1=Newman|first1=L|last2=Rowley|first2=J|last3=Vander Hoorn |first3=S |last4=Wijesooriya|first4=NS|last5=Unemo|first5=M|last6=Low|first6=N|last7=Stevens|first7=G|last8=Gottlieb|first8=S|last9=Kiarie|first9=J|last10=Temmerman|first10=M|title=Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. |journal=PLOS ONE|date=2015|volume=10|issue=12|pages=e0143304|pmid=26646541|doi=10.1371/journal.pone.0143304|pmc=4672879|bibcode=2015PLoSO..1043304N|doi-access=free}}</ref> During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.<ref name=GBD2015Death>{{cite journal|vauthors=((GBD 2015 Mortality and Causes of Death Collaborators)) |title=Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015 |journal=Lancet|date=October 2016 |volume=388 |issue=10053 |pages=1459–1544 |pmid=27733281|doi=10.1016/s0140-6736(16)31012-1|pmc=5388903}}</ref><ref name=Loz2012>{{cite journal|last=Lozano|first=R|title=Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.|journal=Lancet|date=15 December 2012 |volume=380|issue=9859|pages=2095–128|pmid=23245604|doi=10.1016/S0140-6736(12)61728-0|pmc=10790329|hdl=10536/DRO/DU:30050819|s2cid=1541253|url=https://zenodo.org/record/2557786|hdl-access=free|access-date=9 April 2020|archive-date=19 May 2020|archive-url=https://web.archive.org/web/20200519152712/https://zenodo.org/record/2557786|url-status=live}}</ref> After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with [[HIV|human immunodeficiency virus]] (HIV).<ref name=Kent08/><ref name=Music08>{{cite journal |last=Franzen|first=C|title=Syphilis in composers and musicians – Mozart, Beethoven, Paganini, Schubert, Schumann, Smetana|journal= [[European Journal of Clinical Microbiology & Infectious Diseases]] |date=December 2008|volume=27|issue=12|pages=1151–57|pmid=18592279|doi=10.1007/s10096-008-0571-x|s2cid=947291}}</ref> This is believed to be partly due to unsafe drug use, increased [[prostitution]], and decreased use of [[condom]]s.<ref name="Coffin2010">{{cite journal |last1=Coffin |first1=L.S. |last2=Newberry |first2=A. |last3=Hagan |first3=H. |last4=Cleland |first4=C.M. |last5=Des Jarlais |first5=D.C. |last6=Perlman |first6=D.C. |title=Syphilis in Drug Users in Low and Middle Income Countries |journal=The International Journal on Drug Policy |date=January 2010 |volume=21 |issue=1 |pages=20–27 |pmid=19361976 |doi=10.1016/j.drugpo.2009.02.008 |pmc=2790553}}</ref><ref name="Gao2009">{{cite journal |last=Gao |first=L. |author2=Zhang, L. |author3=Jin, Q |title=Meta-analysis: prevalence of HIV infection and syphilis among MSM in China|journal=Sexually Transmitted Infections|date=September 2009 |volume=85|issue=5|pages=354–58|pmid=19351623|doi=10.1136/sti.2008.034702|s2cid=24198278}}</ref><ref name="Karp2009">{{cite journal |last=Karp |first=G. |author2=Schlaeffer, F. |author3=Jotkowitz, A. |author4=Riesenberg, K. |title=Syphilis and HIV co-infection|journal=European Journal of Internal Medicine |date=January 2009|volume=20|issue=1|pages=9–13|pmid=19237085|doi=10.1016/j.ejim.2008.04.002}}</ref>
+In 2015, about 45.4&nbsp;million people had syphilis infections,<ref name=GBD2015Pre>{{cite journal|vauthors=((GBD 2015 Maternal Mortality Collaborators)) |title=Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015 |journal=Lancet|date=October 2016 |volume=388 |issue=10053 |pages=1545–1602 |pmid=27733282 |doi=10.1016/S0140-6736(16)31678-6 |pmc=5055577}}</ref> of which six million were new cases.<ref name=New2015>{{cite journal |last1=Newman|first1=L|last2=Rowley|first2=J|last3=Vander Hoorn |first3=S |last4=Wijesooriya|first4=NS|last5=Unemo|first5=M|last6=Low|first6=N|last7=Stevens|first7=G|last8=Gottlieb|first8=S|last9=Kiarie|first9=J|last10=Temmerman|first10=M|title=Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting. |journal=PLOS ONE|date=2015|volume=10|issue=12|article-number=e0143304|pmid=26646541|doi=10.1371/journal.pone.0143304|pmc=4672879|bibcode=2015PLoSO..1043304N|doi-access=free}}</ref> During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.<ref name=GBD2015Death>{{cite journal|vauthors=((GBD 2015 Mortality and Causes of Death Collaborators)) |title=Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015 |journal=Lancet|date=October 2016 |volume=388 |issue=10053 |pages=1459–1544 |pmid=27733281|doi=10.1016/s0140-6736(16)31012-1|pmc=5388903}}</ref><ref name=Loz2012>{{cite journal|last=Lozano|first=R|title=Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010.|journal=Lancet|date=15 December 2012 |volume=380|issue=9859|pages=2095–128|pmid=23245604|doi=10.1016/S0140-6736(12)61728-0|pmc=10790329|hdl=10536/DRO/DU:30050819|s2cid=1541253|url=https://zenodo.org/record/2557786|hdl-access=free|access-date=9 April 2020|archive-date=19 May 2020|archive-url=https://web.archive.org/web/20200519152712/https://zenodo.org/record/2557786|url-status=live}}</ref> After decreasing dramatically with the availability of penicillin in the 1940s, rates of infection have increased since the turn of the millennium in many countries, often in combination with [[HIV|human immunodeficiency virus]] (HIV).<ref name=Kent08/><ref name=Music08>{{cite journal |last=Franzen|first=C|title=Syphilis in composers and musicians – Mozart, Beethoven, Paganini, Schubert, Schumann, Smetana|journal= [[European Journal of Clinical Microbiology & Infectious Diseases]] |date=December 2008|volume=27|issue=12|pages=1151–57|pmid=18592279|doi=10.1007/s10096-008-0571-x|s2cid=947291}}</ref> This is believed to be partly due to unsafe drug use, increased [[prostitution]], and decreased use of [[condom]]s.<ref name="Coffin2010">{{cite journal |last1=Coffin |first1=L.S. |last2=Newberry |first2=A. |last3=Hagan |first3=H. |last4=Cleland |first4=C.M. |last5=Des Jarlais |first5=D.C. |last6=Perlman |first6=D.C. |title=Syphilis in Drug Users in Low and Middle Income Countries |journal=The International Journal on Drug Policy |date=January 2010 |volume=21 |issue=1 |pages=20–27 |pmid=19361976 |doi=10.1016/j.drugpo.2009.02.008 |pmc=2790553}}</ref><ref name="Gao2009">{{cite journal |last=Gao |first=L. |author2=Zhang, L. |author3=Jin, Q |title=Meta-analysis: prevalence of HIV infection and syphilis among MSM in China|journal=Sexually Transmitted Infections|date=September 2009 |volume=85|issue=5|pages=354–58|pmid=19351623|doi=10.1136/sti.2008.034702|s2cid=24198278}}</ref><ref name="Karp2009">{{cite journal |last=Karp |first=G. |author2=Schlaeffer, F. |author3=Jotkowitz, A. |author4=Riesenberg, K. |title=Syphilis and HIV co-infection|journal=European Journal of Internal Medicine |date=January 2009|volume=20|issue=1|pages=9–13|pmid=19237085|doi=10.1016/j.ejim.2008.04.002}}</ref>
 {{TOC limit}}
@@ Line 50: / Line 49: @@
 ===Latent===
-Latent syphilis is defined as having [[serology|serologic]] proof of infection without symptoms of disease.<ref name=RedBookSyphilis/> It develops after secondary syphilis and is divided into early latent and late latent stages.<ref name="O'Byrne"/> Early latent syphilis is defined by the [[World Health Organization]] as less than 2 years after original infection.<ref name="O'Byrne">{{cite journal |last1=O'Byrne |first1=Patrick |last2=MacPherson |first2=Paul |title=Syphilis |journal=BMJ |date=28 June 2019 |volume=365 |pages=l4159 |doi=10.1136/bmj.l4159|pmid=31253629 |pmc=6598465 }}</ref> Early latent syphilis is infectious as up to 25% of people can develop a recurrent secondary infection (during which bacteria are actively replicating and are infectious).<ref name="O'Byrne" /> Two years after the original infection the person will enter late latent syphilis and is not as infectious as in the early phase.<ref name=Eye07/><ref>{{cite web |title=Ward 86 Practice Recommendations: Syphilis |url=http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis |website=hivinsite.ucsf.edu |access-date=29 July 2019 |archive-date=29 April 2019 |archive-url=https://web.archive.org/web/20190429161518/http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis |url-status=dead }}</ref> The latent phase of syphilis can last many years after which, without treatment, approximately 15–40% of people can develop tertiary syphilis.<ref>{{cite journal |last1=Peeling |first1=Rosanna W. |last2=Mabey |first2=David |last3=Kamb |first3=Mary L. |last4=Chen |first4=Xiang-Sheng |last5=Radolf |first5=Justin D. |last6=Benzaken |first6=Adele S. |title=Syphilis |journal=Nature Reviews Disease Primers |date=12 October 2017 |volume=3 |issue=1 |pages=17073 |doi=10.1038/nrdp.2017.73|pmid=29022569 |pmc=5809176 }}</ref>
+Latent syphilis is defined as having [[serology|serologic]] proof of infection without symptoms of disease.<ref name=RedBookSyphilis/> It develops after secondary syphilis and is divided into early latent and late latent stages.<ref name="O'Byrne"/> Early latent syphilis is defined by the [[World Health Organization]] as less than 2 years after original infection.<ref name="O'Byrne">{{cite journal |last1=O'Byrne |first1=Patrick |last2=MacPherson |first2=Paul |title=Syphilis |journal=BMJ |date=28 June 2019 |volume=365 |article-number=l4159 |doi=10.1136/bmj.l4159|pmid=31253629 |pmc=6598465 }}</ref> Early latent syphilis is infectious as up to 25% of people can develop a recurrent secondary infection (during which bacteria are actively replicating and are infectious).<ref name="O'Byrne" /> Two years after the original infection the person will enter late latent syphilis and is not as infectious as in the early phase.<ref name=Eye07/><ref>{{cite web |title=Ward 86 Practice Recommendations: Syphilis |url=http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis |website=hivinsite.ucsf.edu |access-date=29 July 2019 |archive-date=29 April 2019 |archive-url=https://web.archive.org/web/20190429161518/http://hivinsite.ucsf.edu/InSite?page=md-ward86-syphilis }}</ref> The latent phase of syphilis can last many years after which, without treatment, approximately 15–40% of people can develop tertiary syphilis.<ref>{{cite journal |last1=Peeling |first1=Rosanna W. |last2=Mabey |first2=David |last3=Kamb |first3=Mary L. |last4=Chen |first4=Xiang-Sheng |last5=Radolf |first5=Justin D. |last6=Benzaken |first6=Adele S. |title=Syphilis |journal=Nature Reviews Disease Primers |date=12 October 2017 |volume=3 |issue=1 |page=17073 |doi=10.1038/nrdp.2017.73|pmid=29022569 |pmc=5809176 }}</ref>
 ===Tertiary===
@@ Line 65: / Line 64: @@
 ===Congenital===
-{{main|Congenital syphilis}}
+{{Main|Congenital syphilis}}
-Congenital syphilis is that which is transmitted during pregnancy or during birth.<ref name=Wood09/> Two-thirds of syphilitic infants are born without symptoms.<ref name=Wood09/> Common symptoms that develop over the first couple of years of life include [[hepatosplenomegaly|enlargement of the liver and spleen]] (70%), rash (70%), fever (40%), neurosyphilis (20%), and [[pneumonitis|lung inflammation]] (20%).<ref name=Wood09/> If untreated, [[late congenital syphilis]] may occur in 40%, including [[saddle nose]] deformation, [[Higouménakis' sign]], [[saber shin]], or [[Clutton's joints]] among others.<ref name=Wood09/> Infection during pregnancy is also associated with [[miscarriage]].<ref name="Will2013">{{cite book|title=Williams Obstetrics|last=Cunningham|first=F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS|publisher=McGraw-Hill|year=2013|pages=5|chapter=Abortion}}</ref> The main dental defects seen in congenital syphilis are the peg-shaped, notched incisors known as [[Hutchinson's teeth]] and so-called [[mulberry molars]] (also known as Moon or Fournier molars), defective permanent molars with rounded, deformed crowns resembling a [[mulberry]].<ref name="Phillips">{{cite journal |author1=Nissanka-Jayasuriya EH |author2=Odell EW |author3=Phillips C |date=September 2016 |title=Dental Stigmata of Congenital Syphilis: A Historic Review With Present Day Relevance. |journal=Head Neck Pathol |volume=10 |issue=3 |pages=327–331 |pmid=26897633|pmc=4972761 |doi=10.1007/s12105-016-0703-z}}</ref>
+Congenital syphilis is that which is transmitted during pregnancy or during birth.<ref name=Wood09/> Two-thirds of syphilitic infants are born without symptoms.<ref name=Wood09/> Common symptoms that develop over the first couple of years of life include [[hepatosplenomegaly|enlargement of the liver and spleen]] (70%), rash (70%), fever (40%), neurosyphilis (20%), and [[pneumonitis|lung inflammation]] (20%).<ref name=Wood09/> If untreated, [[late congenital syphilis]] may occur in 40%, including [[saddle nose]] deformation, [[Higouménakis' sign]], [[saber shin]], or [[Clutton's joints]] among others.<ref name=Wood09/> Infection during pregnancy is also associated with [[miscarriage]].<ref name="Will2013">{{Cite book |vauthors=Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS |year=2013 |chapter=Abortion |title=Williams Obstetrics |edition=24th |location=New York |publisher=McGraw-Hill |page=5}}</ref> The main dental defects seen in congenital syphilis are the peg-shaped, notched incisors known as [[Hutchinson's teeth]] and so-called [[mulberry molars]] (also known as Moon or Fournier molars), defective permanent molars with rounded, deformed crowns resembling a [[mulberry]].<ref name="Phillips">{{Cite journal |author1=Nissanka-Jayasuriya EH |author2=Odell EW |author3=Phillips C |date=September 2016 |title=Dental Stigmata of Congenital Syphilis: A Historic Review with Present Day Relevance |journal=Head Neck Pathol |volume=10 |issue=3 |pages=327–331 |doi=10.1007/s12105-016-0703-z |pmid=26897633 |pmc=4972761}}</ref>
 ==Cause==
@@ Line 73: / Line 73: @@
 [[File:Treponema pallidum 01.png|thumb|upright=1.4|[[Histopathology]] of ''Treponema pallidum'' bacteria using a modified [[Silver stain|Steiner silver stain]], 1986|alt=]]
-''Treponema pallidum'' subspecies ''pallidum'' is a spiral-shaped, [[Gram-negative]], highly mobile bacterium.<ref name=Music08/><ref name=Pri2008/> Two other human diseases are caused by related ''Treponema pallidum'' subspecies, [[yaws]] (subspecies ''pertenue'')  and [[nonvenereal endemic syphilis|bejel]] (subspecies ''endemicum''), and one further caused by the very closely related  ''Treponema carateum'', [[Pinta (disease)|pinta]].<ref name=Kent08/><ref>{{cite journal |vauthors=Giacani L, Lukehart SA |title=The endemic treponematoses |journal=Clinical Microbiology Reviews |volume=27 |issue=1 |pages=89–115 |date=January 2014 |pmid=24396138 |pmc=3910905 |doi=10.1128/CMR.00070-13}}</ref> Unlike subspecies ''pallidum'', they do not cause neurological disease.<ref name=Wood09/> Humans are the only known [[natural reservoir]] for subspecies ''pallidum''.<ref name=ST10>{{Cite journal |last1=Stamm |first1=LV |title=Global challenge of antibiotic-resistant ''Treponema pallidum'' |journal=Antimicrobial Agents and Chemotherapy|date=February 2010|volume=54|issue=2|pages=583–89|pmid=19805553|doi=10.1128/aac.01095-09|pmc=2812177}}</ref> It is unable to survive more than a few days without a [[Host (biology)|host]].<ref name=Pri2008/> This is due to its small genome (1.14[[base pair|Mbp]]) failing to encode the metabolic pathways necessary to make most of its macronutrients.<ref name=Pri2008/> It has a slow [[doubling time]] of greater than 30&nbsp;hours.<ref name=Pri2008/> The bacterium is known for its ability to evade the immune system and its invasiveness.<ref>{{Cite journal |last1=Peeling |first1=RW |last2=Mabey |first2=D |last3=Kamb |first3=ML |last4=Chen |first4=XS |last5=Radolf |first5=JD |last6=Benzaken |first6=AS |title=Syphilis. |journal=Nature Reviews. Disease Primers |date=12 October 2017 |volume=3 |pages=17073 |doi=10.1038/nrdp.2017.73 |pmid=29022569 |pmc=5809176 }}</ref>
+''Treponema pallidum'' subspecies ''pallidum'' is a spiral-shaped, [[Gram-negative]], highly mobile bacterium.<ref name=Music08/><ref name=Pri2008/> Two other human diseases are caused by related ''Treponema pallidum'' subspecies, [[yaws]] (subspecies ''pertenue'')  and [[nonvenereal endemic syphilis|bejel]] (subspecies ''endemicum''), and one further caused by the very closely related  ''Treponema carateum'', [[Pinta (disease)|pinta]].<ref name=Kent08/><ref>{{cite journal |vauthors=Giacani L, Lukehart SA |title=The endemic treponematoses |journal=Clinical Microbiology Reviews |volume=27 |issue=1 |pages=89–115 |date=January 2014 |pmid=24396138 |pmc=3910905 |doi=10.1128/CMR.00070-13}}</ref> Unlike subspecies ''pallidum'', they do not cause neurological disease.<ref name=Wood09/> Humans are the only known [[natural reservoir]] for subspecies ''pallidum''.<ref name=ST10>{{Cite journal |last1=Stamm |first1=LV |title=Global challenge of antibiotic-resistant ''Treponema pallidum'' |journal=Antimicrobial Agents and Chemotherapy|date=February 2010|volume=54|issue=2|pages=583–89|pmid=19805553|doi=10.1128/aac.01095-09|pmc=2812177}}</ref> It is unable to survive more than a few days without a [[Host (biology)|host]].<ref name=Pri2008/> This is due to its small genome (1.14&nbsp;[[base pair|Mbp]]) failing to encode the metabolic pathways necessary to make most of its macronutrients.<ref name=Pri2008/> It has a slow [[doubling time]] of greater than 30&nbsp;hours.<ref name=Pri2008/> The bacterium is known for its ability to evade the immune system and its invasiveness.<ref>{{Cite journal |last1=Peeling |first1=R. W. |last2=Mabey |first2=D. |last3=Kamb |first3=M. L. |last4=Chen |first4=X. S. |last5=Radolf |first5=J. D. |last6=Benzaken |first6=A. S. |title=Syphilis |journal=Nature Reviews. Disease Primers |date=12 October 2017 |volume=3 |article-number=17073 |doi=10.1038/nrdp.2017.73 |pmid=29022569 |pmc=5809176 }}</ref>
 ===Transmission===
-Syphilis is transmitted primarily by sexual contact or during [[pregnancy]] from a mother to her baby; the bacterium is able to pass through intact mucous membranes or compromised skin.<ref name=Kent08/><ref name=ST10/> It is thus transmissible by [[kissing]] near a lesion, as well as [[Non-penetrative sex#Manual sex|manual]], [[Oral sex|oral]], [[Vaginal sex|vaginal]], and [[anal sex]].<ref name=Kent08/><ref name=CDC2004/><ref>{{cite book| last1 = Hoyle | first1 = Alice | last2 = McGeeney | first2 = Ester |title=Great Relationships and Sex Education|publisher=Taylor and Francis|year=2019|access-date=11 July 2023|isbn=978-1-35118-825-8|url=https://books.google.com/books?id=KE7ADwAAQBAJ&pg=PT261}}</ref> Approximately 30% to 60% of those exposed to primary or secondary syphilis will get the disease.<ref name=Eye07>{{cite journal |author=Bhatti MT |title=Optic neuropathy from viruses and spirochetes |journal=Int Ophthalmol Clin |volume=47 |issue=4 |pages=37–66, ix |year=2007 |pmid=18049280 |doi=10.1097/IIO.0b013e318157202d |s2cid=2011299 }}</ref> Its [[infectivity]] is exemplified by the fact that an individual [[Inoculation|inoculated]] with only 57 organisms has a 50% chance of being infected.<ref name=Pri2008/> Most new cases in the United States (60%) occur in men who have sex with men; and in this population 20% of syphilis cases were due to oral sex alone.<ref name=Kent08/><ref name="CDC2004">{{cite web |title=Transmission of Primary and Secondary Syphilis by Oral Sex --- Chicago, Illinois, 1998–2002 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm |website=Morbidity and Mortality Weekly Report |publisher=[[Centers for Disease Control and Prevention|CDC]] |language=en |date=21 October 2004 |access-date=15 January 2019 |archive-date=5 August 2020 |archive-url=https://web.archive.org/web/20200805010501/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm |url-status=live }}</ref> Syphilis can be transmitted by [[blood product]]s, but the risk is low due to screening of [[Blood donation|donated blood]] in many countries.<ref name=Kent08/> The risk of transmission from [[sharing needles]] appears to be limited.<ref name=Kent08/>
+Syphilis is transmitted primarily by sexual contact or during [[pregnancy]] from a mother to her baby; the bacterium is able to pass through intact mucous membranes or compromised skin.<ref name=Kent08/><ref name=ST10/> It is thus transmissible by [[kissing]] near a lesion, as well as [[Non-penetrative sex#Manual sex|manual]], [[Oral sex|oral]], [[Vaginal sex|vaginal]], and [[anal sex]].<ref name=Kent08/><ref name=CDC2004/><ref>{{cite book| last1 = Hoyle | first1 = Alice | last2 = McGeeney | first2 = Ester |title=Great Relationships and Sex Education|publisher=Taylor and Francis|year=2019|access-date=11 July 2023|isbn=978-1-35118-825-8|url=https://books.google.com/books?id=KE7ADwAAQBAJ&pg=PT261}}</ref> Approximately 30% to 60% of those exposed to primary or secondary syphilis will get the disease.<ref name=Eye07>{{cite journal |vauthors=Bhatti MT |title=Optic neuropathy from viruses and spirochetes |journal=International Ophthalmology Clinics |volume=47 |issue=4 |pages=37–66, ix |year=2007 |pmid=18049280 |doi=10.1097/IIO.0b013e318157202d |s2cid=2011299 }}</ref> Its [[infectivity]] is exemplified by the fact that an individual [[Inoculation|inoculated]] with only 57 organisms has a 50% chance of being infected.<ref name=Pri2008/> Most new cases in the United States (60%) occur in men who have sex with men; and in this population 20% of syphilis cases were due to oral sex alone.<ref name=Kent08/><ref name="CDC2004">{{cite web |title=Transmission of Primary and Secondary Syphilis by Oral Sex – Chicago, Illinois, 1998–2002 |url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm |website=Morbidity and Mortality Weekly Report |publisher=[[Centers for Disease Control and Prevention|CDC]] |language=en |date=21 October 2004 |access-date=15 January 2019 |archive-date=5 August 2020 |archive-url=https://web.archive.org/web/20200805010501/https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5341a2.htm |url-status=live }}</ref> Syphilis can be transmitted by [[blood product]]s, but the risk is low due to screening of [[Blood donation|donated blood]] in many countries.<ref name=Kent08/> The risk of transmission from [[sharing needles]] appears to be limited.<ref name=Kent08/>
-It is not generally possible to contract syphilis through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.<ref name=CDC2014>{{cite web |title= Syphilis & MSM (Men Who Have Sex With Men) - CDC Fact Sheet |publisher= [[Centers for Disease Control and Prevention]] (CDC) |date= 16 September 2010 |url= http://m.cdc.gov/en/HealthSafetyTopics/DiseasesConditions/STDs/syphilisMSM_FS |access-date= 18 October 2014 |url-status= dead |archive-url= https://web.archive.org/web/20141024093624/http://m.cdc.gov/en/HealthSafetyTopics/DiseasesConditions/STDs/syphilisMSM_FS |archive-date= 24 October 2014}}</ref> This is mainly because the bacteria die very quickly outside of the body, making transmission by [[fomite|objects]] extremely difficult.<ref name="Csonka1990">{{cite book|author=G. W. Csonka|title=Sexually transmitted diseases: a textbook of genitourinary medicine|url=https://books.google.com/books?id=o6NrAAAAMAAJ|year=1990|publisher=Baillière Tindall|isbn=978-0-7020-1258-7|page=232|url-status=live|archive-url=https://web.archive.org/web/20160503035653/https://books.google.com/books?id=o6NrAAAAMAAJ|archive-date=3 May 2016}}</ref>
+It is not generally possible to contract syphilis through toilet seats, daily activities, hot tubs, or sharing eating utensils or clothing.<ref name=CDC2014>{{cite web |title= Syphilis & MSM (Men Who Have Sex With Men) – CDC Fact Sheet |publisher= [[Centers for Disease Control and Prevention]] (CDC) |date=16 September 2010 |url= http://m.cdc.gov/en/HealthSafetyTopics/DiseasesConditions/STDs/syphilisMSM_FS |access-date= 18 October 2014 |archive-url= https://web.archive.org/web/20141024093624/http://m.cdc.gov/en/HealthSafetyTopics/DiseasesConditions/STDs/syphilisMSM_FS |archive-date= 24 October 2014}}</ref> This is mainly because the bacteria die very quickly outside of the body, making transmission by [[fomite|objects]] extremely difficult.<ref name="Csonka1990">{{cite book|first=G. W. |last=Csonka|title=Sexually transmitted diseases: a textbook of genitourinary medicine|url=https://books.google.com/books?id=o6NrAAAAMAAJ|year=1990|publisher=Baillière Tindall|isbn=978-0-7020-1258-7|page=232|url-status=live|archive-url=https://web.archive.org/web/20160503035653/https://books.google.com/books?id=o6NrAAAAMAAJ|archive-date=3 May 2016}}</ref>
 ==Diagnosis==
 [[File:Syphilis false shame and fear may destroy your future.png|thumb|upright=1.2|alt=Poster for testing of syphilis, showing a man and a woman bowing their heads in shame|This [[Works Progress Administration]] poster ({{circa}} 1936) acknowledges the social stigma of syphilis, while urging those who possibly have the disease to be tested]]
-[[File:Micrograph of secondary syphilis.jpg|thumb|[[Micrograph]] of secondary syphilis skin lesions. (A/B) H&E stain of SS lesions. (C/D) IHC staining reveals abundant bacteria embedded within a mixed cellular inflammatory infiltrate (shown in the red box) in the papillary dermis. The blue arrow points to a tissue histiocyte and the read arrows to two dermal lymphocytes<ref>{{cite journal|last1=Lukehart|first1=Sheila|authorlink1=Sheila Lukehart|last2=Cruz|first2=Adriana R.|last3=Ramirez|first3=Lady G.|last4=Zuluaga|first4=Ana V.|last5=Pillay|first5=Allan|last6=Abreu|first6=Christine|last7=Valencia|first7=Carlos A.|last8=La Vake|first8=Carson|last9=Cervantes|first9=Jorge L.|last10=Dunham-Ems |first10=Star |last11=Cartun |first11=Richard |last12=Mavilio |first12=Domenico |last13=Radolf|first13=Justin D.|last14=Salazar|first14=Juan C.|title=Immune Evasion and Recognition of the Syphilis Spirochete in Blood and Skin of Secondary Syphilis Patients: Two Immunologically Distinct Compartments|journal=PLOS Neglected Tropical Diseases |volume=6 |issue=7 |year=2012 |pages=e1717 |issn=1935-2735 |pmid=22816000 |pmc=3398964 |doi=10.1371/journal.pntd.0001717 |doi-access=free}}</ref>]]
+[[File:Micrograph of secondary syphilis.jpg|thumb|[[Micrograph]] of secondary syphilis skin lesions. (A/B) H&E stain of SS lesions. (C/D) IHC staining reveals abundant bacteria embedded within a mixed cellular inflammatory infiltrate (shown in the red box) in the papillary dermis. The blue arrow points to a tissue histiocyte and the read arrows to two dermal lymphocytes<ref>{{cite journal|last1=Lukehart|first1=Sheila|author-link1=Sheila Lukehart|last2=Cruz|first2=Adriana R.|last3=Ramirez|first3=Lady G.|last4=Zuluaga|first4=Ana V.|last5=Pillay|first5=Allan|last6=Abreu|first6=Christine|last7=Valencia|first7=Carlos A.|last8=La Vake|first8=Carson|last9=Cervantes|first9=Jorge L.|last10=Dunham-Ems |first10=Star |last11=Cartun |first11=Richard |last12=Mavilio |first12=Domenico |last13=Radolf|first13=Justin D.|last14=Salazar|first14=Juan C.|title=Immune Evasion and Recognition of the Syphilis Spirochete in Blood and Skin of Secondary Syphilis Patients: Two Immunologically Distinct Compartments|journal=PLOS Neglected Tropical Diseases |volume=6 |issue=7 |year=2012 |article-number=e1717 |issn=1935-2735 |pmid=22816000 |pmc=3398964 |doi=10.1371/journal.pntd.0001717 |doi-access=free}}</ref>]]
 Syphilis is difficult to diagnose clinically during early infection.<ref name=Pri2008/> Confirmation is either via [[blood tests]] or direct visual inspection using [[Dark-field microscopy|dark field microscopy]].<ref name=Kent08/><ref>{{cite journal |last1=Ratnam |first1=S |title=The laboratory diagnosis of syphilis. |journal=Canadian Journal of Infectious Diseases and Medical Microbiology |date=January 2005 |volume=16 |issue=1 |pages=45–51 |doi=10.1155/2005/597580 |pmid=18159528|pmc=2095002 |doi-access=free}}</ref> Blood tests are more commonly used, as they are easier to perform.<ref name=Kent08/> Diagnostic tests are unable to distinguish between the stages of the disease.<ref name="Orgin10">{{cite journal |last=Farhi |first=D |author2=Dupin, N |date=September–October 2010 |title=Origins of syphilis and management in the immunocompetent patient: facts and controversies |journal=Clinics in Dermatology |volume=28 |issue=5 |pages=533–8 |doi=10.1016/j.clindermatol.2010.03.011 |pmid=20797514}}</ref>
@@ Line 101: / Line 101: @@
 ===Sex===
-[[Condom]] use reduces the likelihood of transmission during sex, but does not eliminate the risk.<ref>{{cite journal |date=July 2009|title=A systematic review of epidemiologic studies assessing condom use and risk of syphilis|journal=Sex Transm Dis|volume=36|issue=7|pages=401–5|doi=10.1097/OLQ.0b013e3181a396eb|pmid=19455075|vauthors=Koss CA, Dunne EF, Warner L|s2cid=25571961}}</ref> The [[Centers for Disease Control and Prevention]] (CDC) states, "Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected.<ref>{{cite web |title=Condom Fact Sheet in Brief {{!}} CDC |url=https://www.cdc.gov/condomeffectiveness/brief.html |website=www.cdc.gov |access-date=29 July 2019 |date=18 April 2019 |archive-date=26 July 2019 |archive-url=https://web.archive.org/web/20190726042736/https://www.cdc.gov/condomeffectiveness/brief.html |url-status=live }}</ref> However, a syphilis sore outside of the area covered by a latex condom can still allow transmission, so caution should be exercised even when using a condom."<ref name="CDC Fact Sheet"/>
+[[Condom]] use reduces the likelihood of transmission during sex, but does not eliminate the risk.<ref>{{cite journal |date=July 2009|title=A systematic review of epidemiologic studies assessing condom use and risk of syphilis|journal=Sexually Transmitted Diseases|volume=36|issue=7|pages=401–5|doi=10.1097/OLQ.0b013e3181a396eb|pmid=19455075|vauthors=Koss CA, Dunne EF, Warner L|s2cid=25571961}}</ref> The [[Centers for Disease Control and Prevention]] (CDC) states, "Correct and consistent use of latex condoms can reduce the risk of syphilis only when the infected area or site of potential exposure is protected. However, a syphilis sore outside of the area covered by a latex condom can still allow transmission, so caution should be exercised even when using a condom."<ref name="CDC Fact Sheet"/>
-[[Abstinence]] from intimate physical contact with an infected person is effective at reducing the transmission of syphilis. The CDC states, "The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually [[monogamous]] relationship with a partner who has been tested and is known to be uninfected."<ref name="CDC Fact Sheet">{{cite web |title= Syphilis - CDC Fact Sheet |publisher= [[Centers for Disease Control and Prevention]] (CDC) |date= 16 September 2010 |url= https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |access-date= 30 May 2007 |url-status= live |archive-url= https://web.archive.org/web/20120916073018/http://www.cdc.gov/std/syphilis/STDFact-Syphilis-detailed.htm |archive-date= 16 September 2012}}</ref>
+[[Abstinence]] from intimate physical contact with an infected person is effective at reducing the transmission of syphilis. The CDC states, "The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually [[monogamous]] relationship with a partner who has been tested and is known to be uninfected."<ref name="CDC Fact Sheet">{{cite web |title= Syphilis – CDC Fact Sheet |publisher= [[Centers for Disease Control and Prevention]] (CDC) |date= 16 September 2010 |url= https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm |access-date= 30 May 2007 |url-status= live |archive-url= https://web.archive.org/web/20120916073018/http://www.cdc.gov/std/syphilis/STDFact-Syphilis-detailed.htm |archive-date= 16 September 2012}}</ref>
 ===Congenital disease===
 [[File:Portrait of Mr. J. Kay, afflicted with a rodent disease. Unknown artist, c. 1820 CE. The Wellcome Collection, London.jpg|thumb|Portrait of a man affected with what is now believed to have been congenital syphilis, {{circa|1820}}<ref>{{cite web|title=A young man, J. Kay, afflicted with a rodent disease which has eaten away part of his face. Oil painting, ca. 1820.|url=https://wellcomelibrary.org/item/b16031179#?c=0&m=0&s=0&cv=0|website=wellcomelibrary.org|access-date=28 July 2017|url-status=live|archive-url=https://web.archive.org/web/20170728084800/https://wellcomelibrary.org/item/b16031179#?c=0&m=0&s=0&cv=0|archive-date=28 July 2017}}</ref>]]
-Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected.<ref name=Screening04>{{cite journal |last=Schmid|first=G|title=Economic and programmatic aspects of congenital syphilis prevention|journal=Bulletin of the World Health Organization|date=June 2004|volume=82|issue=6|pages=402–9|pmid=15356931|pmc=2622861}}</ref> The [[United States Preventive Services Task Force]] (USPSTF) strongly recommends universal screening of all pregnant women,<ref>{{cite journal |last=U.S. Preventive Services Task|first=Force|title=Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement|journal=Annals of Internal Medicine|date=19 May 2009 |volume=150|issue=10|pages=705–9|pmid=19451577|doi=10.7326/0003-4819-150-10-200905190-00008|doi-access=free}}</ref> while the [[World Health Organization]] (WHO) recommends all women be tested at their first antenatal visit and again in the [[third trimester]].<ref name=Lancet11/><ref>{{cite web |title=Prenatal Syphilis Screening Laws |url=https://www.cdc.gov/std/treatment/syphilis-screenings-2018.htm |website=www.cdc.gov |access-date=29 July 2019 |date=8 April 2019 |archive-date=28 July 2019 |archive-url=https://web.archive.org/web/20190728221453/https://www.cdc.gov/std/treatment/syphilis-screenings-2018.htm |url-status=live }}</ref> If they are positive, it is recommended their partners also be treated.<ref name=Lancet11/> Congenital syphilis is still common in the developing world, as many women do not receive [[antenatal care]] at all, and the antenatal care others receive does not include screening.<ref name=Screening04/><ref>{{cite journal |last1=Phiske |first1=MM |title=Current trends in congenital syphilis. |journal=Indian Journal of Sexually Transmitted Diseases and AIDS |date=January 2014 |volume=35 |issue=1 |pages=12–20 |doi=10.4103/0253-7184.132404 |pmid=24958980|pmc=4066591 |doi-access=free }}</ref> It still occasionally occurs in the developed world, as those most likely to acquire syphilis are least likely to receive care during pregnancy.<ref name=Screening04/> Several measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.<ref name=Lancet11>{{cite journal |last=Hawkes|first=S|author2=Matin, N |author3=Broutet, N |author4=Low, N |title=Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis|journal=The Lancet Infectious Diseases|date=15 June 2011 |pmid=21683653|volume=11|issue=9|pages=684–91|doi=10.1016/S1473-3099(11)70104-9}}</ref> [[Point-of-care testing]] to detect syphilis appeared to be reliable, although more research is needed to assess its effectiveness and into improving outcomes in mothers and babies.<ref>{{cite journal |last1=Shahrook|first1=S|last2=Mori|first2=R|last3=Ochirbat|first3=T|last4=Gomi|first4=H|title=Strategies of testing for syphilis during pregnancy.|journal=The Cochrane Database of Systematic Reviews|date=29 October 2014|volume=2014|issue=10|pages=CD010385|pmid=25352226|doi=10.1002/14651858.CD010385.pub2|pmc=11126892}}</ref>
+Congenital syphilis in the newborn can be prevented by screening mothers during early pregnancy and treating those who are infected.<ref name=Screening04>{{cite journal |last=Schmid|first=G|title=Economic and programmatic aspects of congenital syphilis prevention|journal=Bulletin of the World Health Organization|date=June 2004|volume=82|issue=6|pages=402–9|pmid=15356931|pmc=2622861}}</ref> The [[United States Preventive Services Task Force]] (USPSTF) strongly recommends universal screening of all pregnant women,<ref>{{cite journal |last=U.S. Preventive Services Task|first=Force|title=Screening for syphilis infection in pregnancy: U.S. Preventive Services Task Force reaffirmation recommendation statement|journal=Annals of Internal Medicine|date=19 May 2009 |volume=150|issue=10|pages=705–9|pmid=19451577|doi=10.7326/0003-4819-150-10-200905190-00008|doi-access=free}}</ref> while the [[World Health Organization]] (WHO) recommends all women be tested at their first antenatal visit and again in the [[third trimester]].<ref name=Lancet11/><ref>{{cite web |title=Prenatal Syphilis Screening Laws |url=https://www.cdc.gov/std/treatment/syphilis-screenings-2018.htm |website=www.cdc.gov |access-date=29 July 2019 |date=8 April 2019 |archive-date=28 July 2019 |archive-url=https://web.archive.org/web/20190728221453/https://www.cdc.gov/std/treatment/syphilis-screenings-2018.htm |url-status=live }}</ref> If they are positive, it is recommended their partners also be treated.<ref name=Lancet11/> Congenital syphilis is still common in the developing world, as many women do not receive [[antenatal care]] at all, and the antenatal care others receive does not include screening.<ref name=Screening04/><ref>{{cite journal |last1=Phiske |first1=MM |title=Current trends in congenital syphilis. |journal=Indian Journal of Sexually Transmitted Diseases and AIDS |date=January 2014 |volume=35 |issue=1 |pages=12–20 |doi=10.4103/0253-7184.132404 |pmid=24958980|pmc=4066591 |doi-access=free }}</ref> It still occasionally occurs in the developed world, as those most likely to acquire syphilis are least likely to receive care during pregnancy.<ref name=Screening04/> Several measures to increase access to testing appear effective at reducing rates of congenital syphilis in low- to middle-income countries.<ref name=Lancet11>{{cite journal |last=Hawkes|first=S|author2=Matin, N |author3=Broutet, N |author4=Low, N |title=Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis|journal=The Lancet Infectious Diseases|date=15 June 2011 |pmid=21683653|volume=11|issue=9|pages=684–91|doi=10.1016/S1473-3099(11)70104-9}}</ref> [[Point-of-care testing]] to detect syphilis appeared to be reliable, although more research is needed to assess its effectiveness and into improving outcomes in mothers and babies.<ref>{{cite journal |last1=Shahrook|first1=S|last2=Mori|first2=R|last3=Ochirbat|first3=T|last4=Gomi|first4=H|title=Strategies of testing for syphilis during pregnancy.|journal=The Cochrane Database of Systematic Reviews|date=29 October 2014|volume=2014|issue=10|article-number=CD010385|pmid=25352226|doi=10.1002/14651858.CD010385.pub2|pmc=11126892}}</ref>
 ===Screening===
 The CDC recommends that sexually active men who have sex with men be tested at least yearly.<ref>{{cite web|title=Trends in Sexually Transmitted Diseases in the United States: 2009 National Data for Gonorrhea, Chlamydia and Syphilis|url=https://www.cdc.gov/std/stats09/tables/trends-table.htm|publisher=[[Centers for Disease Control and Prevention]]|date=22 November 2010|access-date=3 August 2011|url-status=live|archive-url=https://web.archive.org/web/20110804025120/http://www.cdc.gov/std/stats09/tables/trends-table.htm|archive-date=4 August 2011}}</ref> The USPSTF also recommends screening among those at high risk.<ref>{{cite journal |last1=Bibbins-Domingo|first1=Kirsten|last2=Grossman|first2=David C.|last3=Curry|first3=Susan J.|last4=Davidson|first4=Karina W.|last5=Epling|first5=John W.|last6=García|first6=Francisco A. R.|last7=Gillman|first7=Matthew W.|last8=Harper|first8=Diane M.|last9=Kemper|first9=Alex R.|last10=Krist|first10=Alex H.|last11=Kurth|first11=Ann E.|last12=Landefeld|first12=C. Seth|last13=Mangione|first13=Carol M.|last14=Phillips|first14=William R.|last15=Phipps|first15=Maureen G.|last16=Pignone|first16=Michael P.|title=Screening for Syphilis Infection in Nonpregnant Adults and Adolescents|journal=JAMA|date=7 June 2016|volume=315|issue=21|pages=2321–7|doi=10.1001/jama.2016.5824|pmid=27272583|author1-link=Kirsten Bibbins-Domingo|doi-access=free}}</ref>
-Syphilis is a [[notifiable disease]] in many countries, including Canada,<ref>{{cite web|title=National Notifiable Diseases|url=http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/list-eng.php|publisher=Public Health Agency of Canada|date=5 April 2005|access-date=2 August 2011|url-status=live|archive-url=https://web.archive.org/web/20110809162040/http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/list-eng.php|archive-date=9 August 2011}}</ref> the [[European Union]],<ref>{{cite journal |last=Viñals-Iglesias|first=H|author2=Chimenos-Küstner, E|title=The reappearance of a forgotten disease in the oral cavity: syphilis|journal=Medicina Oral, Patologia Oral y Cirugia Bucal|date=1 September 2009 |volume=14|issue=9|pages=e416–20|pmid=19415060}}</ref> and the United States.<ref>{{cite web|title=Table 6.5. Infectious Diseases Designated as Notifiable at the National Level-United States, 2009 [a]|url=http://www.unboundmedicine.com/redbook/ub/view/RedBook/187389/all/Table_6_5__Infectious_Diseases_Designated_as_Notifiable_at_the_National_Level_United_States__2009_%5Ba%5D|work=Red Book|access-date=2 August 2011|url-status=dead|archive-url=https://archive.today/20120913180413/http://www.unboundmedicine.com/redbook/ub/view/RedBook/187389/all/Table_6_5__Infectious_Diseases_Designated_as_Notifiable_at_the_National_Level_United_States__2009_%5Ba%5D|archive-date=13 September 2012}}</ref> This means health care providers are required to notify [[public health]] authorities, which will then ideally provide [[partner notification]] to the person's partners.<ref>{{cite book|title=Brunner & Suddarth's textbook of medical-surgical nursing.|year=2010|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-8589-1|pages=2144|edition=12th|url=https://books.google.com/books?id=SmtjSD1x688C&pg=PA2144|url-status=live|archive-url=https://web.archive.org/web/20160518012909/https://books.google.com/books?id=SmtjSD1x688C&pg=PA2144|archive-date=18 May 2016}}</ref> Physicians may also encourage patients to send their partners to seek care.<ref>{{cite journal |last=Hogben|first=M|title=Partner notification for sexually transmitted diseases|journal=Clinical Infectious Diseases|date=1 April 2007|volume=44|issue=Suppl 3|pages=S160–74|pmid=17342669|doi=10.1086/511429|doi-access=free}}</ref> Several strategies have been found to improve follow-up for STI testing, including email and text messaging of reminders for appointments.<ref name="DesaiWoodhall2015">{{cite journal|last1=Desai|first1=Monica|last2=Woodhall|first2=Sarah C|last3=Nardone|first3=Anthony|last4=Burns|first4=Fiona|last5=Mercey|first5=Danielle|last6=Gilson|first6=Richard|title=Active recall to increase HIV and STI testing: a systematic review|journal=Sexually Transmitted Infections|volume=91|issue=5|year=2015|pages=sextrans–2014–051930|issn=1368-4973|doi=10.1136/sextrans-2014-051930|pmid=25759476|s2cid=663971|url=http://sti.bmj.com/content/sextrans/91/5/314.full.pdf|doi-access=free|access-date=18 September 2019|archive-date=23 September 2020|archive-url=https://web.archive.org/web/20200923030724/https://sti.bmj.com/content/sextrans/91/5/314.full.pdf|url-status=live}}</ref>
+Syphilis is a [[notifiable disease]] in many countries, including Canada,<ref>{{cite web|title=National Notifiable Diseases|url=http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/list-eng.php|publisher=Public Health Agency of Canada|date=5 April 2005|access-date=2 August 2011|url-status=live|archive-url=https://web.archive.org/web/20110809162040/http://dsol-smed.phac-aspc.gc.ca/dsol-smed/ndis/list-eng.php|archive-date=9 August 2011}}</ref> the [[European Union]],<ref>{{cite journal |last=Viñals-Iglesias|first=H|author2=Chimenos-Küstner, E|title=The reappearance of a forgotten disease in the oral cavity: syphilis|journal=Medicina Oral, Patologia Oral y Cirugia Bucal|date=1 September 2009 |volume=14|issue=9|pages=e416–20|pmid=19415060}}</ref> and the United States.<ref>{{cite web|title=Table 6.5. Infectious Diseases Designated as Notifiable at the National Level-United States, 2009 [a]|url=http://www.unboundmedicine.com/redbook/ub/view/RedBook/187389/all/Table_6_5__Infectious_Diseases_Designated_as_Notifiable_at_the_National_Level_United_States__2009_%5Ba%5D|work=Red Book|access-date=2 August 2011|archive-url=https://archive.today/20120913180413/http://www.unboundmedicine.com/redbook/ub/view/RedBook/187389/all/Table_6_5__Infectious_Diseases_Designated_as_Notifiable_at_the_National_Level_United_States__2009_%5Ba%5D|archive-date=13 September 2012}}</ref> This means health care providers are required to notify [[public health]] authorities, which will then ideally provide [[partner notification]] to the person's partners.<ref>{{cite book|title=Brunner & Suddarth's textbook of medical-surgical nursing.|year=2010|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-0-7817-8589-1|page=2144|edition=12th|url=https://books.google.com/books?id=SmtjSD1x688C&pg=PA2144|url-status=live|archive-url=https://web.archive.org/web/20160518012909/https://books.google.com/books?id=SmtjSD1x688C&pg=PA2144|archive-date=18 May 2016}}</ref> Physicians may also encourage patients to send their partners to seek care.<ref>{{cite journal |last=Hogben|first=M|title=Partner notification for sexually transmitted diseases|journal=Clinical Infectious Diseases|date=1 April 2007|volume=44|issue=Suppl 3|pages=S160–74|pmid=17342669|doi=10.1086/511429|doi-access=free}}</ref> Several strategies have been found to improve follow-up for STI testing, including email and text messaging of reminders for appointments.<ref name="DesaiWoodhall2015">{{cite journal|last1=Desai|first1=Monica|last2=Woodhall|first2=Sarah C|last3=Nardone|first3=Anthony|last4=Burns|first4=Fiona|last5=Mercey|first5=Danielle|last6=Gilson|first6=Richard|title=Active recall to increase HIV and STI testing: a systematic review|journal=Sexually Transmitted Infections|volume=91|issue=5|year=2015|pages=sextrans–2014–051930|issn=1368-4973|doi=10.1136/sextrans-2014-051930|pmid=25759476|s2cid=663971|url=http://sti.bmj.com/content/sextrans/91/5/314.full.pdf|doi-access=free|access-date=18 September 2019|archive-date=23 September 2020|archive-url=https://web.archive.org/web/20200923030724/https://sti.bmj.com/content/sextrans/91/5/314.full.pdf|url-status=live}}</ref>
 ==Treatment==
@@ Line 120: / Line 120: @@
 ===Early infections===
-The first-line treatment for uncomplicated syphilis (primary or secondary stages) remains a single dose of [[Intramuscular injection|intramuscular]] [[benzathine benzylpenicillin]].<ref name=CDC2015a/> The bacterium is highly vulnerable to penicillin when treated early, and a treated individual is typically rendered non-infective in about 24 hours.<ref>{{cite web|url=https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/treatment-follow-up.html|title=Syphilis guide: Treatment and follow-up|date=7 July 2022|publisher=Government of Canada}}</ref> [[Doxycycline]] and [[tetracycline]] are alternative choices for those allergic to penicillin; due to the risk of [[birth defect]]s, these are not recommended for pregnant women.<ref name=CDC2015a>{{cite web|last1=Center for Disease Control and Prevention (CDC)|title=Syphilis-CDC fact sheet|url=https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm|website=CDC|access-date=1 March 2015|url-status=live|archive-url=https://web.archive.org/web/20150225182123/http://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm|archive-date=25 February 2015}}</ref> [[Antibiotic resistance|Resistance]] to [[macrolide]]s, [[rifampicin]], and [[clindamycin]] is often present.<ref name=ST10/> [[Ceftriaxone]], a third-generation [[cephalosporin]] [[antibiotic]], may be as effective as penicillin-based treatment.<ref name=Kent08/> It is recommended that a treated person avoid sex until the sores are healed.<ref name=CDC2014/> In comparison to azithromycin for treatment in early infection, there is lack of strong evidence for superiority of azithromycin to benzathine penicillin G.<ref>{{Cite journal |last1=Bai |first1=Zheng Gang |last2=Wang |first2=Baoxi |last3=Yang |first3=Kehu |last4=Tian |first4=Jin Hui |last5=Ma |first5=Bin |last6=Liu |first6=Yali |last7=Jiang |first7=Lei |last8=Gai |first8=Qiong Yan |last9=He |first9=Xiaodong |last10=Li |first10=Youping |date=13 June 2012 |title=Azithromycin versus penicillin G benzathine for early syphilis |journal=The Cochrane Database of Systematic Reviews |issue=6 |pages=CD007270 |doi=10.1002/14651858.CD007270.pub2 |issn=1469-493X |pmid=22696367|pmc=11337171 }}</ref>
+The first-line treatment for uncomplicated syphilis (primary or secondary stages) remains a single dose of [[Intramuscular injection|intramuscular]] [[benzathine benzylpenicillin]].<ref name=CDC2015a/> The bacterium is highly vulnerable to penicillin when treated early, and a treated individual is typically rendered non-infective in about 24 hours.<ref>{{cite web|url=https://www.canada.ca/en/public-health/services/infectious-diseases/sexual-health-sexually-transmitted-infections/canadian-guidelines/syphilis/treatment-follow-up.html|title=Syphilis guide: Treatment and follow-up|date=7 July 2022|publisher=Government of Canada}}</ref> [[Doxycycline]] and [[tetracycline]] are alternative choices for those allergic to penicillin; due to the risk of [[birth defect]]s, these are not recommended for pregnant women.<ref name=CDC2015a>{{cite web|last1=Center for Disease Control and Prevention (CDC)|title=Syphilis-CDC fact sheet|url=https://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm|website=CDC|access-date=1 March 2015|url-status=live|archive-url=https://web.archive.org/web/20150225182123/http://www.cdc.gov/std/syphilis/stdfact-syphilis-detailed.htm|archive-date=25 February 2015}}</ref> [[Antibiotic resistance|Resistance]] to [[macrolide]]s, [[rifampicin]], and [[clindamycin]] is often present.<ref name=ST10/> [[Ceftriaxone]], a third-generation [[cephalosporin]] [[antibiotic]], may be as effective as penicillin-based treatment.<ref name=Kent08/> It is recommended that a treated person avoid sex until the sores are healed.<ref name=CDC2014/> In comparison to azithromycin for treatment in early infection, there is lack of strong evidence for superiority of azithromycin to benzathine penicillin G.<ref>{{Cite journal |last1=Bai |first1=Zheng Gang |last2=Wang |first2=Baoxi |last3=Yang |first3=Kehu |last4=Tian |first4=Jin Hui |last5=Ma |first5=Bin |last6=Liu |first6=Yali |last7=Jiang |first7=Lei |last8=Gai |first8=Qiong Yan |last9=He |first9=Xiaodong |last10=Li |first10=Youping |date=13 June 2012 |title=Azithromycin versus penicillin G benzathine for early syphilis |journal=The Cochrane Database of Systematic Reviews |issue=6 |article-number=CD007270 |doi=10.1002/14651858.CD007270.pub2 |issn=1469-493X |pmid=22696367|pmc=11337171 }}</ref>
 ===Late infections===
@@ Line 127: / Line 127: @@
 ===Jarisch–Herxheimer reaction===
 [[File:Jarisch-Herxheimer reaction in patient (cropped).jpg|thumb|right|Jarisch–Herxheimer reaction in a person with syphilis and human immunodeficiency virus<ref>{{cite journal |last1=D'Eça Júnior |first1=A |last2=Rodrigues |first2=LDS |last3=Costa |first3=LC |title=Jarisch–Herxheimer reaction in a patient with syphilis and human immunodeficiency virus infection. |journal=Revista da Sociedade Brasileira de Medicina Tropical |date=2017 |volume=51 |issue=6 |pages=877–878 |doi=10.1590/0037-8682-0419-2017 |pmid=30517548|doi-access=free }}</ref>]]
-One of the potential side effects of treatment is the [[Jarisch–Herxheimer reaction]].<ref name=Kent08/> It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscle pains, headache, and a [[tachycardia|fast heart rate]].<ref name="Kent08"/> It is  results from the release of pro-inflammatory cytokines by the immune system in response to [[lipoprotein]]s released from rupturing syphilis bacteria.<ref name=Radolf2006>{{cite book |editor1= Radolf, JD |editor2=Lukehart SA |year=2006 |title=Pathogenic ''Treponema'': Molecular and Cellular Biology |publisher=Caister Academic Press |isbn= 978-1-904455-10-3}}</ref>
+One of the potential side effects of treatment is the [[Jarisch–Herxheimer reaction]].<ref name=Kent08/> It frequently starts within one hour and lasts for 24 hours, with symptoms of fever, muscle pains, headache, and a [[tachycardia|fast heart rate]].<ref name="Kent08"/> It results from the release of pro-inflammatory cytokines by the immune system in response to [[lipoprotein]]s released from rupturing syphilis bacteria.<ref name=Radolf2006>{{cite book |editor1= Radolf, JD |editor2=Lukehart SA |year=2006 |title=Pathogenic ''Treponema'': Molecular and Cellular Biology |publisher=Caister Academic Press |isbn= 978-1-904455-10-3}}</ref>
 ===Pregnancy===
-Penicillin is an effective treatment for syphilis in pregnancy<ref>{{cite journal |last1=Alexander|first1=JM|last2=Sheffield|first2=JS|last3=Sanchez|first3=PJ|last4=Mayfield|first4=J|last5=Wendel GD|first5=Jr|title=Efficacy of treatment for syphilis in pregnancy.|journal=Obstetrics and Gynecology|date=January 1999|volume=93|issue=1|pages=5–8|pmid=9916946|doi=10.1016/s0029-7844(98)00338-x}}</ref> but there is no agreement on which dose or route of delivery is most effective.<ref name=Walk2001>{{cite journal |last1=Walker|first1=GJ|title=Antibiotics for syphilis diagnosed during pregnancy.|journal=The Cochrane Database of Systematic Reviews|date=2001|volume=2010|issue=3|pages=CD001143|pmid=11686978|doi=10.1002/14651858.CD001143|pmc=8407021}}</ref>
+Penicillin is an effective treatment for syphilis in pregnancy<ref>{{cite journal |last1=Alexander|first1=JM|last2=Sheffield|first2=JS|last3=Sanchez|first3=PJ|last4=Mayfield|first4=J|last5=Wendel GD|first5=Jr|title=Efficacy of treatment for syphilis in pregnancy.|journal=Obstetrics and Gynecology|date=January 1999|volume=93|issue=1|pages=5–8|pmid=9916946|doi=10.1016/s0029-7844(98)00338-x}}</ref> but there is no agreement on which dose or route of delivery is most effective.<ref name=Walk2001>{{cite journal |last1=Walker|first1=GJ|title=Antibiotics for syphilis diagnosed during pregnancy.|journal=The Cochrane Database of Systematic Reviews|date=2001|volume=2010|issue=3|article-number=CD001143|pmid=11686978|doi=10.1002/14651858.CD001143|pmc=8407021}}</ref>
 ==Epidemiology==
 {{Main|Epidemiology of syphilis}}
 [[File:Syphilis world map-Deaths per million persons-WHO2012.svg|thumb|upright=1.4|Syphilis deaths per million persons in 2012
-{{Div col|small=yes|colwidth=10em}}{{legend|#ffff20|0–0}}{{legend|#ffc020|1–1}}{{legend|#ffa020|2–3}}{{legend|#ff9a20|4–10}}{{legend|#f08015|11–19}}{{legend|#e06815|20–28}}{{legend|#d85010|29–57}}{{legend|#d02010|58–138}}{{div col end}}]]
+{{Div col|small=yes|colwidth=8em}}{{legend|#ffff20|0–0}}{{legend|#ffc020|1–1}}{{legend|#ffa020|2–3}}{{legend|#ff9a20|4–10}}{{legend|#f08015|11–19}}{{legend|#e06815|20–28}}{{legend|#d85010|29–57}}{{legend|#d02010|58–138}}{{div col end}}]]
 [[Image:Syphilis world map - DALY - WHO2004.svg|thumb|upright=1.4|[[Age adjustment|Age-standardized]] [[disability adjusted life years]] from syphilis per 100,000&nbsp;inhabitants in 2004<ref>{{cite web |url=https://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html |title=Disease and injury country estimates |year=2004 |publisher=[[World Health Organization]] (WHO) |access-date=11 November 2009 |url-status=live |archive-url=https://web.archive.org/web/20091111101009/http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html |archive-date=11 November 2009}}</ref>
 {{Col-begin}}
@@ Line 157: / Line 157: @@
 In 2012, about 0.5% of adults were infected with syphilis, with 6&nbsp;million new cases.<ref name=New2015/> In 1999, it is believed to have infected 12&nbsp;million additional people, with greater than 90% of cases in the [[developing world]].<ref name=ST10/> It affects between 700,000 and 1.6&nbsp;million pregnancies a year, resulting in [[miscarriage]]s, [[stillbirth]]s, and congenital syphilis.<ref name=Wood09/> During 2015, it caused about 107,000 deaths, down from 202,000 in 1990.<ref name="GBD2015Death" /><ref name=Loz2012/> In [[sub-Saharan Africa]], syphilis contributes to approximately 20% of [[perinatal death]]s.<ref name=Wood09/> Rates are proportionally higher among [[Recreational drug use|intravenous drug users]], those who are infected with [[HIV]], and men who have sex with men.<ref name="Coffin2010"/><ref name="Gao2009"/><ref name="Karp2009"/> In the United States about 55,400 people are newly infected each year {{as of|2014|lc=y}}.<ref>{{cite web |title=Syphilis |url=https://www.niaid.nih.gov/diseases-conditions/syphilis |website=www.niaid.nih.gov |date= 27 October 2014|access-date=7 August 2019 |archive-date=7 August 2019 |archive-url=https://web.archive.org/web/20190807014149/https://www.niaid.nih.gov/diseases-conditions/syphilis |url-status=live}}</ref> [[African American]]s accounted for almost half of all cases in 2010.<ref>{{cite web|title=STD Trends in the United States: 2010 National Data for Gonorrhea, Chlamydia, and Syphilis|url=https://www.cdc.gov/std/stats10/tables/trends-table.htm|publisher=[[Centers for Disease Control and Prevention]] (CDC)|date=22 November 2010|access-date=20 November 2011|url-status=live|archive-url=https://web.archive.org/web/20120124104622/http://www.cdc.gov/std/stats10/tables/trends-table.htm|archive-date=24 January 2012}}</ref> As of 2014, syphilis infections continue to increase in the United States.<ref name="ClementOkeke2014">{{cite journal |last1=Clement |first1=Meredith E. |last2=Okeke |first2=N. Lance |last3=Hicks |first3=Charles B. |title=Treatment of Syphilis |journal=JAMA|volume=312|issue=18|pages=1905–17|year=2014|issn=0098-7484|doi=10.1001/jama.2014.13259|pmid=25387188|pmc=6690208}}</ref><ref>{{cite book |last1=Cantor |first1=Amy |last2=Nelson |first2=Heidi D. |last3=Daeges |first3=Monica |last4=Pappas |first4=Miranda |title=Screening for Syphilis in Nonpregnant Adolescents and Adults: Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation |series=U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews |date=2016 |publisher=Agency for Healthcare Research and Quality (US) |pmid=27336106 |url=https://www.ncbi.nlm.nih.gov/books/NBK368467/ |access-date=5 August 2019 |archive-date=8 March 2021 |archive-url=https://web.archive.org/web/20210308105501/https://www.ncbi.nlm.nih.gov/books/NBK368467/ |url-status=live}}</ref> In the United States as of 2020, rates of syphilis have increased by more than threefold; in 2018 approximately 86% of all cases of syphilis in the United States were in men.<ref name=NEJM2020/> In 2021, preliminary CDC data illustrated that 2,677 cases of congenital syphilis were found in the population of 332 million in the United States.<ref>{{cite news |last1=Paperny |first1=Anna Mehler |title=Syphilis cases in babies skyrocket in Canada amid healthcare failures |url=https://www.reuters.com/business/healthcare-pharmaceuticals/syphilis-cases-babies-skyrocket-canada-amid-healthcare-failures-2023-03-31/ |website=reuters|date=31 March 2023 }}</ref>
-Syphilis was very common in Europe during the 18th and 19th centuries.<ref name=Music08/> [[Gustave Flaubert|Flaubert]] found it universal among 19th-century Egyptian prostitutes.<ref>{{cite book|author1=Francis Steegmuller|title=Flaubert in Egypt, A Sensibility on Tour|date=1979|publisher=Chicago Review Press, Incorporated |isbn= 9780897330183}}</ref> In the developed world during the early 20th century, infections declined rapidly with the widespread use of [[antibiotic]]s, until the 1980s and 1990s.<ref name=Music08/> Since 2000, rates of syphilis have been increasing in the US, Canada, the UK, Australia and Europe, primarily among men who have sex with men.<ref name=ST10/> Rates of syphilis among US women have remained stable during this time, while rates among UK women have increased, but at a rate less than that of men.<ref name=AOP08>{{cite journal |last=Kent|first=ME|author2=Romanelli, F |title=Reexamining syphilis: an update on epidemiology, clinical manifestations, and management|journal=Annals of Pharmacotherapy|date=February 2008|volume=42|issue=2|pages=226–36|pmid=18212261|doi=10.1345/aph.1K086|s2cid=23899851}}</ref> Increased rates among heterosexuals have occurred in China and Russia since the 1990s.<ref name=ST10/> This has been attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and decreasing use of barrier protection.<ref name=ST10/><ref name=AOP08/><ref>{{cite journal |last=Ficarra|first=G|author2=Carlos, R |title=Syphilis: The Renaissance of an Old Disease with Oral Implications|journal=Head and Neck Pathology|date=September 2009|volume=3|issue=3|pages=195–206|pmid=20596972|doi=10.1007/s12105-009-0127-0|pmc=2811633}}</ref>
+Syphilis was very common in Europe during the 18th and 19th centuries.<ref name=Music08/> [[Gustave Flaubert|Flaubert]] found it universal among 19th-century Egyptian prostitutes.<ref>{{cite book|author1=Francis Steegmuller|title=Flaubert in Egypt, A Sensibility on Tour|date=1979|publisher=Chicago Review Press, Incorporated |isbn= 978-0-89733-018-3}}</ref> In the developed world during the early 20th century, infections declined rapidly with the widespread use of [[antibiotic]]s, until the 1980s and 1990s.<ref name=Music08/> Since 2000, rates of syphilis have been increasing in the US, Canada, the UK, Australia and Europe, primarily among men who have sex with men.<ref name=ST10/> Rates of syphilis among US women have remained stable during this time, while rates among UK women have increased, but at a rate less than that of men.<ref name=AOP08>{{cite journal |last=Kent|first=ME|author2=Romanelli, F |title=Reexamining syphilis: an update on epidemiology, clinical manifestations, and management|journal=Annals of Pharmacotherapy|date=February 2008|volume=42|issue=2|pages=226–36|pmid=18212261|doi=10.1345/aph.1K086|s2cid=23899851}}</ref> Increased rates among heterosexuals have occurred in China and Russia since the 1990s.<ref name=ST10/> This has been attributed to unsafe sexual practices, such as sexual promiscuity, prostitution, and decreasing use of barrier protection.<ref name=ST10/><ref name=AOP08/><ref>{{cite journal |last=Ficarra|first=G|author2=Carlos, R |title=Syphilis: The Renaissance of an Old Disease with Oral Implications|journal=Head and Neck Pathology|date=September 2009|volume=3|issue=3|pages=195–206|pmid=20596972|doi=10.1007/s12105-009-0127-0|pmc=2811633}}</ref>
-Left untreated, it has a mortality rate of 8% to 58%, with a greater death rate among males.<ref name=Kent08/> The symptoms of syphilis have become less severe over the 19th and 20th centuries, in part due to widespread availability of effective treatment, and partly due to [[virulence]] of the bacteria.<ref name=Sec2010/> With early treatment, few complications result.<ref name=Pri2008/> Syphilis increases the risk of HIV transmission by two to five times, and coinfection is common (30–60% in some urban centers).<ref name=Kent08/><ref name=ST10/> In 2015, [[Cuba]] became the first country to eliminate mother-to-child transmission of syphilis.<ref name=WHOCUba2015>{{cite web|url=https://www.who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/|title= WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba|publisher= [[WHO]]|date= 30 June 2015|access-date= 30 August 2015|url-status= dead|archive-url= https://web.archive.org/web/20150904154356/http://who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/|archive-date= 4 September 2015}}</ref>
+Left untreated, it has a mortality rate of 8% to 58%, with a greater death rate among males.<ref name=Kent08/> The symptoms of syphilis have become less severe over the 19th and 20th centuries, in part due to widespread availability of effective treatment, and partly due to [[virulence]] of the bacteria.<ref name=Sec2010/> With early treatment, few complications result.<ref name=Pri2008/> Syphilis increases the risk of HIV transmission by two to five times, and coinfection is common (30–60% in some urban centers).<ref name=Kent08/><ref name=ST10/> In 2015, [[Cuba]] became the first country to eliminate mother-to-child transmission of syphilis.<ref name=WHOCUba2015>{{cite web|url=https://www.who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/|title= WHO validates elimination of mother-to-child transmission of HIV and syphilis in Cuba|publisher= [[WHO]]|date= 30 June 2015|access-date= 30 August 2015|archive-url= https://web.archive.org/web/20150904154356/http://who.int/mediacentre/news/releases/2015/mtct-hiv-cuba/en/|archive-date= 4 September 2015}}</ref>
 ==History==
@@ Line 165: / Line 165: @@
 === Origin, spread and discovery ===
-[[Image:Rembrandt Harmensz. van Rijn 095.jpg|thumb|Portrait of [[Gerard de Lairesse]] by [[Rembrandt van Rijn]], circa 1665–67, oil on canvas. De Lairesse, himself a painter and art theorist, had congenital syphilis that deformed his face and eventually blinded him<ref>''[[Metropolitan Museum of Art|The Metropolitan Museum of Art Bulletin]]'', Summer 2007, pp. 55–56.</ref>]]
+[[Image:Rembrandt Harmensz. van Rijn 095.jpg|thumb|upright|Portrait of [[Gerard de Lairesse]] by [[Rembrandt van Rijn]], circa 1665–67, oil on canvas. De Lairesse, himself a painter and art theorist, had congenital syphilis that deformed his face and eventually blinded him<ref>''[[Metropolitan Museum of Art|The Metropolitan Museum of Art Bulletin]]'', Summer 2007, pp. 55–56.</ref>]]
 [[Paleopathology|Paleopathologists]] have known for decades that syphilis was present in the Americas before European contact.<ref>{{Cite journal |last=Rothschild |first=B. M. |date=15 May 2005 |title=History of Syphilis |url=https://academic.oup.com/cid/article-lookup/doi/10.1086/429626 |journal=Clinical Infectious Diseases |language=en |volume=40 |issue=10 |pages=1454–1463 |doi=10.1086/429626 |pmid=15844068 |issn=1058-4838}}</ref><ref>Baker, B. J. and Armelagos, G. J., (1988) "The origin and antiquity of syphilis: Paleopathological diagnosis and interpretation". ''Current Anthropology'', 29, 703–738. https://doi.org/10.1086/203691. Powell, M. L. & Cook, D. C. (2005) ''The Myth of Syphilis:'' The natural history of treponematosis in North America. Gainesville, FL: University Press of Florida. Williams, H. (1932) "The origin and antiquity of syphilis: The evidence from diseased bones, a review, with some new material from America". ''Archives of Pathology'', 13: 779–814, 931–983.1932).</ref> The situation in [[Afro-Eurasia]] has been murkier and caused considerable debate.<ref>Dutour, O., et al. (Eds.). (1994). L'origine de la syphilis in Europe: avant ou après 1493? Paris, France: Éditions Errance. Baker, B. J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". ''Yearbook of Physical Anthropology'' 171: 5–41. [[doi: 10.1002/ajpa.23988]]. Harper, K. N., Zuckerman, M. K., Harper, M. L., Kingston, J. D., Armelagos, G. J. (2011) "The origin and antiquity of syphilis revisited: An appraisal of Old World Pre-Columbian evidence of treponemal infections". ''Yearbook of Physical Anthropology'', 54: 99–133. https://doi.org/10.1002/ajpa.21613.</ref> According to the Columbian theory, syphilis was brought to Spain by the men who sailed with [[Christopher Columbus]] in 1492 and spread from there, with a serious epidemic in [[Naples]] beginning as early as 1495. Contemporaries believed the disease sprang from American roots, and in the 16th century physicians wrote extensively about the new disease inflicted on them by the returning explorers.<ref>For an introduction to this literature see Quétel, C. (1990). ''History of Syphilis''. Baltimore, MD: The Johns Hopkins University Press.</ref>
@@ Line 175: / Line 175: @@
 The most compelling evidence for the validity of the pre-Columbian hypothesis is the presence of syphilitic-like damage to bones and teeth in medieval skeletal remains. While the absolute number of cases is not large, new ones are continually discovered, most recently in 2015.<ref>Walker, D., Powers, N., Connell, B., & Redfern, R. (2015). "Evidence of skeletal treponematosis from the Medieval burial ground of St. Mary Spital, London, and implications for the origins of the disease in Europe". ''American Journal of Physical Anthropology'', 156, 90–101. https://doi.org/10.1002/ajpa.22630 and Gaul, J.S., Grossschmidt, K., Budenbauer, C., & Kanz, Fabian (2015). "A probable case of congenital syphilis from pre-Columbian Austria". ''Anthropologischer Anzeiger'', 72, 451–472. [[DOI: 10.1127/anthranz/2015/0504]].</ref> At least fifteen cases of acquired treponematosis based on evidence from bones, and six examples of congenital treponematosis based on evidence from teeth, are now widely accepted. In several of the twenty-one cases the evidence may also indicate syphilis.<ref>They include Henneberg, M., & Henneberg, R. J. (1994). "Treponematosis in an ancient Greek colony of Metaponto, southern Italy, 580-250 BCE". In O. Dutour, et al. (Eds.), ''L'origine de la syphilis in Europe: Avant ou après 1493?'' (pp. 92–98). Paris, France: Éditions Errance. Stirland, Ann. "Evidence for Pre-Columbian Treponematosis in Europe". In Dutour, O., Pálfi, G., Bérato, J., & Brun, J. -P. (Eds.). (1994). ''L'origine de la syphilis in Europe: avant ou après 1493?'' Paris, France: Éditions Errance, and ''Criminals and Paupers: The Graveyard of St. Margaret Fyebriggate in combusto, Norwich''. With Contributions from Brian Ayers and Jayne Brown. East Anglian Archaeology 129. Dereham: Historic Environment, Norfolk Museums and Archaeology Service, 2009. Erdal, Y. S. (2006). "A pre-Columbian case of congenital syphilis from Anatolia (Nicaea, 13th century AD)". ''International Journal of Osteoarchaeology'', 16, 16–33. https://doi.org/10.1002/oa.802. Cole G. and T. Waldron, "Apple Down 152: a putative case of syphilis from sixth century AD Anglo-Saxon England". ''American Journal of Physical Anthropology'' 2011 Jan;144(1):72-9. [[doi: 10.1002/ajpa.21371]]. Epub 2010 Aug 18. PMID 20721939. Roberts, C. A. (1994). "Treponematosis in Gloucester, England: A theoretical and practical approach to the Pre-Columbian theory". In O. Dutour, et al. (Eds.), ''L'origine de la syphilis in Europe: avant ou après 1493?'' (pp. 101–108). Paris, France: Éditions Errance.</ref>
-[[File:Medieval illumination of Christ being tortured.jpg|thumb|A healthy man and a diseased man torture [[Jesus|Christ]] before [[Crucifixion of Jesus|his crucifixion]]. From a French [[book of hours]], {{circa|1375–1435}}]]
+[[File:Medieval illumination of Christ being tortured.jpg|thumb|left|A healthy man and a diseased man torture [[Jesus|Christ]] before [[Crucifixion of Jesus|his crucifixion]]. From a French [[book of hours]], {{circa|1375–1435}}]]
 In 2020, a group of leading paleopathologists concluded that enough evidence had been collected to prove that treponemal disease, almost certainly including syphilis, had existed in Europe prior to the voyages of Columbus.<ref>Baker, B.J. et al. (2020) "Advancing the Understanding of Treponemal Disease in the Past and Present". ''Yearbook of Physical Anthropology'' 171: 5–41. [[doi: 10.1002/ajpa.23988]].</ref> There is an outstanding issue, however. Damaged teeth and bones may seem to hold proof of pre-Columbian syphilis, but there is a possibility that they point to an endemic form of treponemal disease instead. As syphilis, bejel, and yaws vary considerably in mortality rates and the level of human disease they elicit, it is important to know which one is under discussion in any given case, but it remains difficult for paleopathologists to distinguish among them. (The fourth of the treponemal diseases is [[Pinta (disease)|pinta]], a skin disease and therefore unrecoverable through paleopathology.) Ancient [[DNA]] (aDNA) holds the answer, because just as only aDNA suffices to distinguish between syphilis and other diseases that produce similar symptoms in the body, it alone can differentiate [[Spirochaete|spirochetes]] that are 99.8 percent identical with absolute accuracy.<ref>Fraser, C. M., Norris, S. J., Weinstock, G. M., White, O., Sutton, G. G., Dodson, R., ... Venter, J. C. (1998). "Complete genome sequence of ''Treponema pallidum'', the syphilis spirochete". ''Science'', 281(5375), 375–388. https://doi.org/10.1371/journal.pntd.0001832. Čejková, D., Zobaníková, M., Chen, L., Pospíšilová, P., Strouhal, M., Qin, X., ... Šmajs, D. (2012). "Whole genome sequences of three ''Treponema pallidum'' ssp. ''pertenue'' strains: yaws and syphilis treponemes differ in less than 0.2% of the genome sequence". ''PLoS Neglected Tropical Diseases'', 6(1), e1471. [[doi: 10.1371/journal.pone.0015713]]. Mikalová, L., Strouhal, M., Čejková, D., ''Zobaníková'', M., Pospíšilová, P., Norris, S. J., ... Šmajs, D. (2010). "Genome analysis of ''Treponema pallidum'' subsp. ''pallidum'' and subsp. ''pertenue'' strains: Most of the genetic differences are localized in six regions". ''PLoS ONE'', 5, e15713. doi.org/10.1371/journal.pone.0015713. Štaudová, B., Strouhal, M., Zobaníková, M., Čejková, D., Fulton, L. L., Chen, L., ... Šmajs, D. (2014). "Whole genome sequence of the ''Treponema pallidum'' subsp. ''endemicum'' strain Bosnia A: The genome is related to yaws treponemes but contains few loci similar to syphilis treponemes". ''PLoS Neglected Tropical Diseases'', 8(11), e3261. https://doi.org/10.1371/journal.pntd.0003261.</ref> Progress on uncovering the historical extent of syndromes through aDNA remains slow, however, because the bacterium responsible for treponematosis is rare in skeletal remains and fragile, making it notoriously difficult to recover and analyse. Precise dating to the medieval period is not yet possible but work by Kettu Majander et al. uncovering the presence of several different kinds of treponematosis at the beginning of the early modern period argues against its recent introduction from elsewhere. Therefore, they argue, treponematosis—possibly including syphilis—almost certainly existed in medieval Europe.<ref>Majander, K., Pfrengle S., Kocher, A., ..., Kühnert, J. K., Schuenemann, V. J. (2020), "Ancient Bacterial Genomes Reveal a High Diversity of ''Treponema pallidum'' Strains in Early Modern Europe". ''Current Biology'' 30, 3788–3803. Elsevier Inc. [[doi: 10.1016/j.cub.2020.07.058]].</ref>
@@ Line 183: / Line 183: @@
 It remains mysterious why the authors of medieval medical treatises so uniformly refrained from describing syphilis or commenting on its existence in the population. Many may have confused it with other diseases such as leprosy ([[Leprosy|Hansen's disease]]) or [[elephantiasis]]. The great variety of symptoms of treponematosis, the different ages at which the various diseases appear, and its widely divergent outcomes depending on climate and culture, would have added greatly to the confusion of medical practitioners, as indeed they did right down to the middle of the 20th century. In addition, evidence indicates that some writers on disease feared the political implications of discussing a condition more fatal to elites than to commoners. Historian Jon Arrizabalaga has investigated this question for [[Castile (historical region)|Castile]] with startling results revealing an effort to hide its association with elites.<ref>Arrizabalaga, Jon. "The Changing Identity of the French Pox in Early Renaissance Castile". In ''Between Text and Patient: The Medical Enterprise in Medieval and Early Modern Europe'', edited by Florence Eliza Glaze and Brian K. Nance, 397–417. Florence: SISMEL, 2011.</ref>
-The first written records of an outbreak of syphilis in Europe occurred in 1495 in [[Naples|Naples, Italy]], during a French invasion ([[Italian War of 1494–98]]).<ref name="Music08" /><ref name="Orgin10" /> Since it was claimed to have been spread by French troops, it was initially called the "French disease" by the people of Naples.<ref>{{cite book|last1=Winters|first1=Adam|title=Syphilis|date=2006|publisher=Rosen Pub. Group|location=New York|isbn=9781404209060|page=17|url=https://books.google.com/books?id=1A0yMoQaMC0C&pg=PT16|access-date=15 September 2017|archive-date=18 August 2020|archive-url=https://web.archive.org/web/20200818163738/https://books.google.com/books?id=1A0yMoQaMC0C&pg=PT16|url-status=live}}</ref> The disease reached [[London]] in 1497 and was recorded at St Bartholomew's Hospital as infecting 10 out of the 20 patients.<ref>Hidden Killers of the Tudor Home: The Horrors of Tudor Dentistry etc</ref> In 1530, the pastoral name "syphilis" (the name of a character) was first used by the Italian physician and poet [[Girolamo Fracastoro]] as the title of his [[Latin]] poem in [[dactylic hexameter]] ''[[Syphilis sive morbus gallicus]]'' (''Syphilis or The French Disease'') describing the ravages of the disease in Italy.<ref>{{cite book|last1=Dormandy|first1=Thomas|title=The worst of evils: man's fight against pain: a history|date=2006|publisher=Yale University Press|location=New Haven|isbn=978-0300113228|page=[https://archive.org/details/worstofevilsmans00dorm/page/99 99]|edition=Uncorrected page proof.|url-access=registration|url=https://archive.org/details/worstofevilsmans00dorm/page/99}}</ref><ref>{{cite book|author1=Anthony Grafton|title=New Worlds, Ancient Texts The Power of Tradition and the Shock of Discovery|date=March 1995|publisher=Harvard University Press|isbn=9780674618763|pages=159–194|chapter=Drugs and Diseases: New World Biology and Old World Learning}}</ref> In Great Britain it was also called the "Great Pox".<ref name="Old05">{{cite journal |last=Dayan|first=L|author2=Ooi, C |title=Syphilis treatment: old and new|journal=Expert Opinion on Pharmacotherapy|date=October 2005|volume=6|issue=13|pages=2271–80|pmid=16218887|doi=10.1517/14656566.6.13.2271|s2cid=6868863}}</ref><ref name="Euro04">{{cite journal|last=Knell|first=RJ|title=Syphilis in renaissance Europe: rapid evolution of an introduced sexually transmitted disease?|journal=Proceedings: Biological Sciences|date=7 May 2004|volume=271|pages=S174–6|pmid=15252975|doi=10.1098/rsbl.2003.0131|pmc=1810019|issue=Suppl 4}}</ref>
+The first written records of an outbreak of syphilis in Europe occurred in 1495 in [[Naples|Naples, Italy]], during a French invasion ([[Italian War of 1494–1495]]).<ref name="Music08" /><ref name="Orgin10" /> Since it was claimed to have been spread by French troops, it was initially called the "French disease" by the people of Naples.<ref>{{cite book|last1=Winters|first1=Adam|title=Syphilis|date=2006|publisher=Rosen|location=New York|isbn=978-1-4042-0906-0|page=17|url=https://books.google.com/books?id=1A0yMoQaMC0C&pg=PT16|access-date=15 September 2017|archive-date=18 August 2020|archive-url=https://web.archive.org/web/20200818163738/https://books.google.com/books?id=1A0yMoQaMC0C&pg=PT16|url-status=live}}</ref> The disease reached [[London]] in 1497 and was recorded at St Bartholomew's Hospital as infecting 10 out of the 20 patients.<ref>''Hidden Killers of the Tudor Home: The Horrors of Tudor Dentistry etc''</ref>{{fcn|reason=Insufficient detail to identify and verify this source|date=October 2025}} In 1530, the pastoral name "syphilis" (the name of a character) was first used by the Italian physician and poet [[Girolamo Fracastoro]] as the title of his [[Latin]] poem in [[dactylic hexameter]], {{lang|la|[[Syphilis sive morbus gallicus]]}} (''Syphilis or The French Disease''), describing the ravages of the disease in Italy.<ref>{{cite book|last1=Dormandy|first1=Thomas|title=The worst of evils: man's fight against pain: a history|date=2006|publisher=Yale University Press|location=New Haven, Connecticut|isbn=978-0-300-11322-8|page=[https://archive.org/details/worstofevilsmans00dorm/page/99 99]|edition=uncorrected page proof|url-access=registration|url=https://archive.org/details/worstofevilsmans00dorm/page/99}}</ref><ref>{{cite book|first1=Anthony |last1=Grafton|title=New Worlds, Ancient Texts The Power of Tradition and the Shock of Discovery|date=March 1995|publisher=Harvard University Press|isbn=978-0-674-61876-3|pages=159–194|chapter=Drugs and Diseases: New World Biology and Old World Learning}}</ref> In Great Britain it was also called the "Great Pox".<ref name="Old05">{{cite journal |last1=Dayan|first1=L.|last2=Ooi |first2=C. |title=Syphilis treatment: old and new|journal=Expert Opinion on Pharmacotherapy|date=October 2005|volume=6|issue=13|pages=2271–2280|pmid=16218887|doi=10.1517/14656566.6.13.2271|s2cid=6868863}}</ref><ref name="Euro04">{{cite journal|last=Knell|first=R. J.|title=Syphilis in renaissance Europe: rapid evolution of an introduced sexually transmitted disease?|journal=Proceedings: Biological Sciences|date=7 May 2004|volume=271|pages=S174–6|pmid=15252975|doi=10.1098/rsbl.2003.0131|pmc=1810019|issue=Suppl 4}}</ref>
-In the 16th through 19th centuries, syphilis was one of the largest public health burdens in [[prevalence]], symptoms, and disability,<ref name="de_Kruif_1932">{{cite book |author=de Kruif, Paul |author-link=Paul de Kruif |chapter=Ch. 7: Schaudinn: The Pale Horror |title=Men Against Death |publisher=Harcourt, Brace |location=New York |year=1932 |oclc=11210642 |chapter-url=https://books.google.com/books?id=IokwAAAAIAAJ&q=editions:IokwAAAAIAAJ |access-date=30 September 2020 |archive-date=28 August 2021 |archive-url=https://web.archive.org/web/20210828011939/https://books.google.com/books?id=IokwAAAAIAAJ&q=editions%3AIokwAAAAIAAJ |url-status=live }}</ref>{{rp|208–209}}<ref name="pmid_">{{cite journal |last1=Rayment |first1=Michael |last2=Sullivan |first2=Ann K |date=April 2011 |title="He who knows syphilis knows medicine"—the return of an old friend |journal=British Journal of Cardiology |volume=18 |pages=56–58 |url=https://bjcardio.co.uk/2011/04/he-who-knows-syphilis-knows-medicine-the-return-of-an-old-friend/ |department=Editorials |quote="He who knows syphilis knows medicine" said Father of Modern Medicine, Sir William Osler, at the turn of the 20th Century. So common was syphilis in days gone by, all physicians were attuned to its myriad clinical presentations. Indeed, the 19th century saw the development of an entire medical subspecialty – syphilology – devoted to the study of the great imitator, ''[[Treponema pallidum]]''. |access-date=7 April 2018 |archive-date=7 August 2020 |archive-url=https://web.archive.org/web/20200807164844/https://bjcardio.co.uk/2011/04/he-who-knows-syphilis-knows-medicine-the-return-of-an-old-friend/ |url-status=live }}</ref> although records of its true prevalence were generally not kept because of the fearsome and sordid status of [[sexually transmitted infections]] in those centuries.<ref name="de_Kruif_1932"/>{{rp|208–209}} According to a 2020 study, more than 20% of individuals in the age range 15–34 years in late 18th-century London were treated for syphilis.<ref>{{cite journal |last1=Szreter |first1=Simon |last2=Siena |first2=Kevin |title=The pox in Boswell's London: an estimate of the extent of syphilis infection in the metropolis in the 1770s† |journal=The Economic History Review |year=2020|volume=74|issue=2|pages=372–399 |doi=10.1111/ehr.13000|issn=1468-0289|doi-access=free}}</ref> At the time the [[causative agent]] was unknown but it was well known that it was spread sexually and also often from mother to child. Its association with sex, especially [[sexual promiscuity]] and [[prostitution]], made it an object of fear and revulsion and a taboo. The magnitude of its morbidity and mortality in those centuries reflected that, unlike today, there was no adequate understanding of its [[pathogenesis]] and no truly effective treatments. Its damage was caused not so much by great sickness or death early in the course of the disease but rather by its gruesome effects decades after infection as it progressed to [[neurosyphilis]] with [[tabes dorsalis]]. [[Mercury (element)|Mercury]] compounds and isolation were commonly used, with treatments often worse than the disease.<ref name="Old05"/>
+In the 16th through 19th centuries, syphilis was one of the largest public health burdens in [[prevalence]], symptoms, and disability,<ref name="de_Kruif_1932">{{cite book |last=de Kruif |first=Paul |author-link=Paul de Kruif |chapter=Ch. 7: Schaudinn: The Pale Horror |title=Men Against Death |publisher=Harcourt, Brace |location=New York |year=1932 |oclc=11210642 |chapter-url=https://books.google.com/books?id=IokwAAAAIAAJ&q=editions:IokwAAAAIAAJ |access-date=30 September 2020 |archive-date=28 August 2021 |archive-url=https://web.archive.org/web/20210828011939/https://books.google.com/books?id=IokwAAAAIAAJ&q=editions%3AIokwAAAAIAAJ |url-status=live }}</ref>{{rp|208–209}}<ref name="pmid_">{{cite journal |last1=Rayment |first1=Michael |last2=Sullivan |first2=Ann K. |date=April 2011 |title='He who knows syphilis knows medicine'—the return of an old friend |journal=British Journal of Cardiology |volume=18 |pages=56–58 |url=https://bjcardio.co.uk/2011/04/he-who-knows-syphilis-knows-medicine-the-return-of-an-old-friend/ |department=Editorials |quote='He who knows syphilis knows medicine' said Father of Modern Medicine, Sir William Osler, at the turn of the 20th Century. So common was syphilis in days gone by, all physicians were attuned to its myriad clinical presentations. Indeed, the 19th century saw the development of an entire medical subspecialty – syphilology – devoted to the study of the great imitator, ''[[Treponema pallidum]]''. |access-date=7 April 2018 |archive-date=7 August 2020 |archive-url=https://web.archive.org/web/20200807164844/https://bjcardio.co.uk/2011/04/he-who-knows-syphilis-knows-medicine-the-return-of-an-old-friend/ |url-status=live }}</ref> although records of its true prevalence were generally not kept because of the fearsome and sordid status of [[sexually transmitted infections]] in those centuries.<ref name="de_Kruif_1932"/>{{rp|208–209}} According to a 2020 study, more than 20% of individuals in the age range 15–34 years in late 18th-century London were treated for syphilis.<ref>{{cite journal |last1=Szreter |first1=Simon |last2=Siena |first2=Kevin |title=The pox in Boswell's London: an estimate of the extent of syphilis infection in the metropolis in the 1770s† |journal=The Economic History Review |year=2020|volume=74|issue=2|pages=372–399 |doi=10.1111/ehr.13000|issn=1468-0289|doi-access=free}}</ref> At the time the [[causative agent]] was unknown but it was well known that it was spread sexually and also often from mother to child. Its association with sex, especially [[sexual promiscuity]] and [[prostitution]], made it an object of fear and revulsion and a taboo. The magnitude of its morbidity and mortality in those centuries reflected that, unlike today, there was no adequate understanding of its [[pathogenesis]] and no truly effective treatments. Its damage was caused not so much by great sickness or death early in the course of the disease but rather by its gruesome effects decades after infection as it progressed to [[neurosyphilis]] with [[tabes dorsalis]]. [[Mercury (element)|Mercury]] compounds and isolation were commonly used, with treatments often worse than the disease.<ref name="Old05"/>
-The causative organism, ''Treponema pallidum'', was first identified by [[Fritz Schaudinn]] and [[Erich Hoffmann]], in 1905.<ref name=Schaudinn1905>{{cite journal| last1 = Schaudinn| first1 = Fritz Richard| author-link1 = Fritz Richard Schaudinn| last2 = Hoffmann| first2 = Erich| author-link2 = Erich Hoffmann| year = 1905| title = Vorläufiger Bericht über das Vorkommen von Spirochaeten in syphilitischen Krankheitsprodukten und bei Papillomen| trans-title = Preliminary report on the occurrence of Spirochaetes in syphilitic chancres and papillomas| journal = [[Arbeiten aus dem Kaiserlichen Gesundheitsamte]]| volume = 22| pages = 527–534| url = https://archive.org/stream/bub_gb_TPkAAAAAYAAJ#page/n535/mode/2up}}</ref> The first effective treatment for syphilis was [[arsphenamine]], discovered by [[Sahachiro Hata]] in 1909, during a survey of hundreds of newly synthesized organic [[arsenic]]al compounds led by [[Paul Ehrlich]]. It was manufactured and marketed from 1910 under the trade name [[Salvarsan]] by [[Hoechst AG]].<ref>{{cite magazine |url=http://pubs.acs.org/cen/coverstory/83/8325/8325salvarsan.html |title=Salvarsan |access-date=1 February 2010 |magazine=[[Chemical & Engineering News]] |archive-date=10 October 2018 |archive-url=https://web.archive.org/web/20181010053811/http://pubs.acs.org/cen/coverstory/83/8325/8325salvarsan.html |url-status=live }}</ref> This [[Organoarsenic chemistry|organoarsenic compound]] was the first modern [[Antimicrobial chemotherapy|chemotherapeutic agent]].
+The causative organism, ''Treponema pallidum'', was first identified by [[Fritz Schaudinn]] and [[Erich Hoffmann]], in 1905.<ref name=Schaudinn1905>{{cite journal| last1 = Schaudinn| first1 = Fritz Richard| author-link1 = Fritz Richard Schaudinn| last2 = Hoffmann| first2 = Erich| author-link2 = Erich Hoffmann| year = 1905| title = Vorläufiger Bericht über das Vorkommen von Spirochaeten in syphilitischen Krankheitsprodukten und bei Papillomen|language=de| trans-title = Preliminary report on the occurrence of Spirochaetes in syphilitic chancres and papillomas| journal = [[Arbeiten aus dem Kaiserlichen Gesundheitsamte]]| volume = 22| pages = 527–534| url = https://archive.org/stream/bub_gb_TPkAAAAAYAAJ#page/n535/mode/2up}}</ref> The first effective treatment for syphilis was [[arsphenamine]], discovered by [[Sahachiro Hata]] in 1909, during a survey of hundreds of newly synthesized organic [[arsenic]]al compounds led by [[Paul Ehrlich]]. It was manufactured and marketed from 1910 under the trade name [[Salvarsan]] by [[Hoechst AG]].<ref>{{cite magazine |url=http://pubs.acs.org/cen/coverstory/83/8325/8325salvarsan.html |title=Salvarsan |access-date=1 February 2010 |magazine=[[Chemical & Engineering News]] |archive-date=10 October 2018 |archive-url=https://web.archive.org/web/20181010053811/http://pubs.acs.org/cen/coverstory/83/8325/8325salvarsan.html |url-status=live }}</ref> This [[Organoarsenic chemistry|organoarsenic compound]] was the first modern [[Antimicrobial chemotherapy|chemotherapeutic agent]].
-During the 20th century, as both [[microbiology]] and [[pharmacology]] advanced greatly, syphilis, like many other infectious diseases, became more of a manageable burden than a scary and disfiguring mystery, at least in [[developed countries]] among those people who could afford to pay for timely diagnosis and treatment. Penicillin was discovered in 1928, and effectiveness of treatment with [[penicillin]] was confirmed in trials in 1943,<ref name="Old05"/> at which time it became the main treatment.<ref name=pmid24653750>{{cite journal |last1=Tampa |first1=M |last2=Sarbu |first2=I |last3=Matei |first3=C |last4=Benea |first4=V |last5=Georgescu |first5=SR |title=Brief History of Syphilis |journal=Journal of Medicine and Life |date=15 March 2014 |volume=7 |issue=1 |pages=4–10 |pmid=24653750 |pmc=3956094 }}</ref>
+During the 20th century, as both [[microbiology]] and [[pharmacology]] advanced greatly, syphilis, like many other infectious diseases, became more of a manageable burden than a scary and disfiguring mystery, at least in [[developed countries]] among those people who could afford to pay for timely diagnosis and treatment. Penicillin was discovered in 1928, and effectiveness of treatment with [[penicillin]] was confirmed in trials in 1943,<ref name="Old05"/> at which time it became the main treatment.<ref name=pmid24653750>{{cite journal |last1=Tampa |first1=M. |last2=Sarbu |first2=I. |last3=Matei |first3=C. |last4=Benea |first4=V. |last5=Georgescu |first5=S. R. |title=Brief History of Syphilis |journal=Journal of Medicine and Life |date=15 March 2014 |volume=7 |issue=1 |pages=4–10 |pmid=24653750 |pmc=3956094 }}</ref>
-Many famous historical figures, including [[Franz Schubert]], [[Arthur Schopenhauer]], [[Édouard Manet]],<ref name=Music08/> [[Charles Baudelaire]],<ref>{{cite book|last1=Hayden|first1=Deborah|title=Pox: Genius, Madness, and the Mysteries of Syphilis|date=2008|publisher=Basic Books|isbn=978-0786724130|page=113|url=https://books.google.com/books?id=p8wM1Y4opdQC&pg=PA113|access-date=15 September 2017|archive-date=19 August 2020|archive-url=https://web.archive.org/web/20200819172057/https://books.google.com/books?id=p8wM1Y4opdQC&pg=PA113|url-status=live}}</ref> and [[Guy de Maupassant]] are believed to have had the disease.<ref>{{cite web|last1=Halioua|first1=Bruno|title=Comment la syphilis emporta Maupassant {{!}} La Revue du Praticien|url=http://www.larevuedupraticien.fr/histoire-de-la-medecine/comment-la-syphilis-emporta-maupassant|website=www.larevuedupraticien.fr|access-date=29 November 2016|date=30 June 2003|url-status=live|archive-url=https://web.archive.org/web/20160602081305/http://www.larevuedupraticien.fr/histoire-de-la-medecine/comment-la-syphilis-emporta-maupassant|archive-date=2 June 2016}}</ref> [[Friedrich Nietzsche]] was long believed to have gone mad as a result of [[tertiary syphilis]], but that diagnosis has recently come into question.<ref>{{cite encyclopedia |last=Bernd |first=Magnus |title=Nietzsche, Friedrich |url=http://www.britannica.com/EBchecked/topic/414670/Friedrich-Nietzsche |encyclopedia=Encyclopædia Britannica |access-date=19 May 2012|url-status=live |archive-url=https://web.archive.org/web/20120723024352/http://www.britannica.com/EBchecked/topic/414670/Friedrich-Nietzsche|archive-date=23 July 2012}}</ref>
+Many famous historical figures, including [[Franz Schubert]], [[Arthur Schopenhauer]], [[Édouard Manet]],<ref name=Music08/> [[Charles Baudelaire]],<ref>{{cite book|last1=Hayden|first1=Deborah|title=Pox: Genius, Madness, and the Mysteries of Syphilis|date=2008|publisher=Basic Books|isbn=978-0-7867-2413-0|page=113|url=https://books.google.com/books?id=p8wM1Y4opdQC&pg=PA113|access-date=15 September 2017|archive-date=19 August 2020|archive-url=https://web.archive.org/web/20200819172057/https://books.google.com/books?id=p8wM1Y4opdQC&pg=PA113|url-status=live}}</ref> and [[Guy de Maupassant]] are believed to have had the disease.<ref>{{cite web|last1=Halioua|first1=Bruno|title=Comment la syphilis emporta Maupassant |trans-title=How syphilis took Maupassant|website=La Revue du Praticien|language=fr|url=http://www.larevuedupraticien.fr/histoire-de-la-medecine/comment-la-syphilis-emporta-maupassant|access-date=29 November 2016|date=30 June 2003|url-status=live|archive-url=https://web.archive.org/web/20160602081305/http://www.larevuedupraticien.fr/histoire-de-la-medecine/comment-la-syphilis-emporta-maupassant|archive-date=2 June 2016}}</ref> [[Friedrich Nietzsche]] was long believed to have gone mad as a result of [[tertiary syphilis]], but that diagnosis has recently come into question.<ref>{{cite encyclopedia |last=Bernd |first=Magnus |title=Nietzsche, Friedrich |url=http://www.britannica.com/EBchecked/topic/414670/Friedrich-Nietzsche |encyclopedia=Encyclopædia Britannica |access-date=19 May 2012|url-status=live |archive-url=https://web.archive.org/web/20120723024352/http://www.britannica.com/EBchecked/topic/414670/Friedrich-Nietzsche|archive-date=23 July 2012}}</ref>
 <!--
 This is a **brief** list of "historical figures", not modern people. Please don't add names of people from the 20th or 21st centuries. Further examples may be appropriate for [[History of syphilis]]. Thanks.
@@ Line 198: / Line 198: @@
 ===Arts and literature===
 {{See also|List of syphilis cases}}
-[[File:400Behandlung der Syphilis.jpg|thumb|An early medical illustration of people with syphilis, Vienna, 1498]]
+[[File:400Behandlung der Syphilis.jpg|thumb|upright|An early medical illustration of people with syphilis, Vienna, 1498]]
-The earliest known depiction of an individual with syphilis is [[Albrecht Dürer]]'s ''[[Syphilitic Man]]'' (1496), a woodcut believed to represent a [[Landsknecht]], a Northern European [[mercenary]].<ref>{{cite journal |last=Eisler |first=CT |title=Who is Dürer's "Syphilitic Man"? |journal=Perspectives in Biology and Medicine |volume=52 |issue=1 |pages=48–60 |date=Winter 2009 |pmid=19168944 |s2cid=207268142 |doi=10.1353/pbm.0.0065}}</ref> The myth of the ''[[femme fatale]]'' or "poison women" of the 19th century is believed to be partly derived from the devastation of syphilis, with classic examples in literature including [[John Keats]]' "[[La Belle Dame sans Merci]]".<ref>{{cite book|last=Hughes|first=Robert|title=Things I didn't know: a memoir|year=2007|publisher=Vintage|location=New York|isbn=978-0-307-38598-7|page=346|edition=1st Vintage Book}}</ref><ref>{{cite book|last=Wilson|first=Elizabeth |editor-first=Joanne |editor-last=Entwistle |title=Body dressing|year=2005|publisher=Berg Publishers|location=Oxford|isbn=978-1-85973-444-5|page=205|edition=[Online-Ausg.]}}</ref>
-The Flemish artist [[Stradanus]] designed a print called ''Preparation and Use of Guayaco for Treating Syphilis'', a scene of a wealthy man receiving treatment for syphilis with the tropical wood [[guaiacum]] sometime around 1590.<ref>{{cite book|last=Reid|first=Basil A.|title=Myths and realities of Caribbean history|year=2009|publisher=University of Alabama Press|location=Tuscaloosa, AL|isbn=978-0-8173-5534-0|pages=113|url=https://books.google.com/books?id=KtT0_P-9xiAC&pg=PA113|edition=[Online-Ausg.]|url-status=live|archive-url=https://web.archive.org/web/20160202071727/https://books.google.com/books?id=KtT0_P-9xiAC&pg=PA113|archive-date=2 February 2016}}</ref>
+The earliest known depiction of an individual with syphilis is [[Albrecht Dürer]]'s ''[[Syphilitic Man]]'' (1496), a woodcut believed to represent a [[Landsknecht]], a Northern European [[mercenary]].<ref>{{cite journal |last=Eisler |first=C. T. |title=Who is Dürer's 'Syphilitic Man'? |journal=Perspectives in Biology and Medicine |volume=52 |issue=1 |pages=48–60 |date=Winter 2009 |pmid=19168944 |s2cid=207268142 |doi=10.1353/pbm.0.0065}}</ref> The myth of the {{lang|fr|[[femme fatale]]}} or "poison women" of the 19th century is believed to be partly derived from the devastation of syphilis, with classic examples in literature including [[John Keats]]' {{lang|fr|italic=no|"[[La Belle Dame sans Merci]]"}}.<ref>{{cite book|last=Hughes|first=Robert|title=Things I didn't know: a memoir|year=2007|publisher=Vintage|location=New York|isbn=978-0-307-38598-7|page=346|edition=1st Vintage Book}}</ref><ref>{{cite book|last=Wilson|first=Elizabeth |editor-first=Joanne |editor-last=Entwistle |title=Body dressing|year=2005|publisher=Berg|location=Oxford|isbn=978-1-85973-444-5|page=205}}</ref>
+The Flemish artist [[Stradanus]] designed a print called ''Preparation and Use of [[Guaiacum officinale|Guayaco]] for Treating Syphilis'', a scene of a wealthy man receiving treatment for syphilis with the tropical wood [[guaiacum]] sometime around 1590.<ref>{{cite book|last=Reid|first=Basil A.|title=Myths and realities of Caribbean history|year=2009|publisher=University of Alabama Press|location=Tuscaloosa, Alabama|isbn=978-0-8173-5534-0|page=113|url=https://books.google.com/books?id=KtT0_P-9xiAC&pg=PA113|url-status=live|archive-url=https://web.archive.org/web/20160202071727/https://books.google.com/books?id=KtT0_P-9xiAC&pg=PA113|archive-date=2 February 2016}}</ref>
 ===Tuskegee and Guatemala studies===
 {{see also|Tuskegee syphilis experiment|Guatemala syphilis experiment}}
-[[File:Stop syphilis LCCN98509573.jpg|thumb|left|A [[Work Projects Administration]] poster about syphilis c. 1940|alt=]]
+[[File:Stop syphilis LCCN98509573.jpg|thumb|left|upright|A [[Work Projects Administration]] poster about syphilis c. 1940]]
-The "Tuskegee Study of Untreated Syphilis in the Negro Male" was an infamous, unethical and racist [[clinical study]] conducted between 1932 and 1972 by the [[U.S. Public Health Service]].<ref name=Brandt>{{cite journal |last=Brandt |first=Allan M. |title=Racism and Research: The Case of the Tuskegee Syphilis Study |url=http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372911 |url-status=live |journal=The Hastings Center Report |volume=8 |issue=6 |pages=21–29 |date=December 1978 |access-date=9 December 2020 |jstor=3561468 |pmid=721302 |doi=10.2307/3561468 |s2cid=215820823 |archive-url=https://web.archive.org/web/20210118011339/https://dash.harvard.edu/handle/1/3372911 |archive-date=18 January 2021|url-access=subscription }}</ref><ref name="timeline">{{cite web |url=https://www.cdc.gov/tuskegee/timeline.htm |title=Tuskegee Study – Timeline |work=NCHHSTP |publisher=CDC |date=25 June 2008 |access-date=4 December 2008 |archive-date=3 September 2011 |archive-url=https://web.archive.org/web/20110903161044/http://www.cdc.gov/tuskegee/timeline.htm |url-status=live}}</ref> Whereas the purpose of this study was to observe the [[Natural history of disease|natural history]] of untreated syphilis; the African-American men in the study were told they were receiving free treatment for "bad blood" from the United States government.<ref>{{Cite book|title=Examining Tuskegee : the infamous syphilis study and its legacy|author=Reverby, Susan M.|date=2009|publisher=University of North Carolina Press|isbn=9780807833100|location=Chapel Hill|oclc=496114416}}</ref>
+The "Tuskegee Study of Untreated Syphilis in the Negro Male" was an infamous, unethical and racist [[clinical study]] conducted between 1932 and 1972 by the [[U.S. Public Health Service]].<ref name=Brandt>{{cite journal |last=Brandt |first=Allan M. |title=Racism and Research: The Case of the Tuskegee Syphilis Study |url=http://nrs.harvard.edu/urn-3:HUL.InstRepos:3372911 |url-status=live |journal=The Hastings Center Report |volume=8 |issue=6 |pages=21–29 |date=December 1978 |access-date=9 December 2020 |jstor=3561468 |pmid=721302 |doi=10.2307/3561468 |s2cid=215820823 |archive-url=https://web.archive.org/web/20210118011339/https://dash.harvard.edu/handle/1/3372911 |archive-date=18 January 2021|url-access=subscription }}</ref><ref name="timeline">{{cite web |url=https://www.cdc.gov/tuskegee/timeline.htm |title=Tuskegee Study – Timeline |publisher=National Center for HIV, Viral Hepatitis, STD, and Tuberculosis, [[Centers for Disease Control and Prevention]] |date=25 June 2008 |access-date=4 December 2008 |archive-date=3 September 2011 |archive-url=https://web.archive.org/web/20110903161044/http://www.cdc.gov/tuskegee/timeline.htm |url-status=live}}</ref> Whereas the purpose of this study was to observe the [[Natural history of disease|natural history]] of untreated syphilis, the African-American men in the study were told they were receiving free treatment for "bad blood" from the United States government.<ref>{{Cite book|title=Examining Tuskegee: the infamous syphilis study and its legacy|last=Reverby |first=Susan M.|date=2009|publisher=University of North Carolina Press|isbn=978-0-8078-3310-0|location=Chapel Hill|oclc=496114416}}</ref>
 The Public Health Service started working on this study in 1932 in collaboration with [[Tuskegee University]], a [[historically black college]] in Alabama. Researchers enrolled 600 poor, African American [[sharecroppers]] from [[Macon County, Alabama|Macon County]], [[Alabama]] in the study. Of these men, 399 had contracted syphilis before the study began, and 201 did not have the disease.<ref name="timeline"/> Medical care, hot meals and free burial insurance were given to those who participated. The men were told that the study would last six months, but in the end, it continued for 40 years.<ref name="timeline" /> After funding for treatment was lost, the study was continued without informing the men that they were only being studied and would not be treated. Facing insufficient participation, the Macon County Health Department nevertheless wrote to subjects to offer them a "last chance" to get a special "treatment", which was not a treatment at all, but a spinal tap administered exclusively for diagnostic purposes.<ref name="Brandt" /> None of the men infected were ever told that they had the disease, and none were treated with [[penicillin]] even after the antibiotic had been proven to successfully treat syphilis. According to the [[Centers for Disease Control]], the men were told they were being treated for "bad blood"—a colloquialism describing various conditions such as fatigue, [[anemia]] and syphilis—which was a leading cause of death among southern African American men.<ref name="timeline"/>
-The 40-year study became a textbook example of criminally negligent [[medical ethics]] because researchers had knowingly withheld treatment with [[penicillin]] and because the subjects had been misled concerning the purposes of the study. The revelation in 1972 of these study failures by a [[whistleblower]], [[Peter Buxtun]], led to major changes in U.S. law and regulation on the protection of participants in clinical studies. Now studies require [[informed consent]],<ref name="hhs.gov">{{cite web |title=Code of Federal Regulations Title 45 Part 46 Protections of Human Subjects 46.1.1(i) |url=https://www.hhs.gov/ohrp/sites/default/files/ohrp/policy/ohrpregulations.pdf |url-status=live |publisher=[[U.S. Department of Health and Human Services]] |date=15 January 2009 |access-date=22 February 2010 |archive-url=https://web.archive.org/web/20160328191725/http://www.hhs.gov/ohrp/policy/ohrpregulations.pdf |archive-date=28 March 2016}}</ref> communication of [[diagnosis]], and accurate reporting of test results.<ref>{{cite web |title=Final Report of the Tuskegee Syphilis Study Legacy Committee |url=http://exhibits.hsl.virginia.edu/badblood/report/ |url-status=dead |publisher=University of Virginia |date=May 1996 |access-date=5 August 2019 |archive-url=https://web.archive.org/web/20170705123612/http://exhibits.hsl.virginia.edu/badblood/report |archive-date=5 July 2017}}</ref>
+[[File:De ontdekking van Guaiacum als middel tegen syfilis, anoniem, Museum Plantin-Moretus, PK OPB 0186 007.jpg|thumb|upright|''Preparation and Use of Guayaco for Treating Syphilis'', after [[Stradanus]], 1590]]
-[[File:De ontdekking van Guaiacum als middel tegen syfilis, anoniem, Museum Plantin-Moretus, PK OPB 0186 007.jpg|thumb|299px|''Preparation and Use of Guayaco for Treating Syphilis'', after [[Stradanus]], 1590]]
+The 40-year study became a textbook example of criminally negligent [[medical ethics]] because researchers had knowingly withheld treatment with [[penicillin]] and because the subjects had been misled concerning the purposes of the study. The revelation in 1972 of these study failures by a [[whistleblower]], [[Peter Buxtun]], led to major changes in U.S. law and regulation on the protection of participants in clinical studies. Now studies require [[informed consent]],<ref name="hhs.gov">{{cite web |title=Code of Federal Regulations Title 45 Part 46 Protections of Human Subjects 46.1.1(i) |url=https://www.hhs.gov/ohrp/sites/default/files/ohrp/policy/ohrpregulations.pdf |url-status=live |publisher=[[U.S. Department of Health and Human Services]] |date=15 January 2009 |access-date=22 February 2010 |archive-url=https://web.archive.org/web/20160328191725/http://www.hhs.gov/ohrp/policy/ohrpregulations.pdf |archive-date=28 March 2016}}</ref> communication of [[diagnosis]], and accurate reporting of test results.<ref>{{cite web |title=Final Report of the Tuskegee Syphilis Study Legacy Committee |work=Bad Blood: The Tuskegee Syphilis Study |url=http://exhibits.hsl.virginia.edu/badblood/report/ |publisher=University of Virginia |date=May 1996 |access-date=5 August 2019 |archive-url=https://web.archive.org/web/20170705123612/http://exhibits.hsl.virginia.edu/badblood/report |archive-date=5 July 2017}}</ref>
-Similar experiments were carried out in [[Guatemala]] from 1946 to 1948. It was done during the administration of American President [[Harry S. Truman]] and Guatemalan President [[Juan José Arévalo]] with the cooperation of some Guatemalan health ministries and officials.<ref name=CDCFactScheet>{{cite web |title=Fact Sheet on the 1946-1948 U.S. Public Health Service Sexually Transmitted Diseases (STD) Inoculation Study |url=https://www.hhs.gov/1946inoculationstudy/factsheet.html |url-status=dead |publisher=U.S. Department of Health and Human Services |date=n.d. |access-date=15 April 2013 |archive-url=https://web.archive.org/web/20130425164618/http://www.hhs.gov/1946inoculationstudy/factsheet.html |archive-date=25 April 2013}}</ref> Doctors infected soldiers, prostitutes, prisoners and [[mental patient]]s with syphilis and other [[sexually transmitted infection]]s, without the [[informed consent]] of the subjects and treated most subjects with [[antibiotic]]s. The experiment resulted in at least 83 deaths.<ref name="BBC20110829">{{cite news |url=https://www.bbc.co.uk/news/world-latin-america-14712089 |title=Guatemalans "died" in 1940s US syphilis study |date=29 August 2011 |publisher=[[BBC News]] |access-date=29 August 2011 |archive-date=1 December 2019 |archive-url=https://web.archive.org/web/20191201011231/https://www.bbc.co.uk/news/world-latin-america-14712089 |url-status=live}}</ref><ref name=PHR>{{cite journal |last=Reverby |first=Susan M. |title=Ethical Failures and History Lessons: The U.S. Public Health Service Research Studies in Tuskegee and Guatemala |journal=Public Health Reviews |date=3 June 2012 |volume=34 |issue=1 |doi=10.1007/BF03391665 |doi-access=free}}</ref> In October 2010, the U.S. formally apologized to Guatemala for the ethical violations that took place. Secretary of State [[Hillary Clinton]] and Health and Human Services Secretary [[Kathleen Sebelius]] stated "Although these events occurred more than 64 years ago, we are outraged that such reprehensible research could have occurred under the guise of public health. We deeply regret that it happened, and we apologize to all the individuals who were affected by such abhorrent research practices."<ref name=NPRapology>{{cite news |first=Scott|last=Hensley|title=U.S. Apologizes For Syphilis Experiments in Guatemala |url=https://www.npr.org/blogs/health/2010/10/01/130266301/u-s-apologizes-for-medical-research-that-infected-guatemalans-with-syphilis |work=[[National Public Radio]] |date=1 October 2010 |access-date=1 October 2010|archive-url=https://web.archive.org/web/20141110013859/http://www.npr.org/blogs/health/2010/10/01/130266301/u-s-apologizes-for-medical-research-that-infected-guatemalans-with-syphilis|archive-date=10 November 2014}}</ref> The experiments were led by physician [[John Charles Cutler]] who also participated in the late stages of the Tuskegee syphilis experiment.<ref name=guardian>{{cite news|author=Chris McGreal|title=US says sorry for "outrageous and abhorrent" Guatemalan syphilis tests|url=https://www.theguardian.com/world/2010/oct/01/us-apology-guatemala-syphilis-tests|access-date=2 October 2010|work=[[The Guardian]]|quote=Conducted between 1946 and 1948, the experiments were led by John Cutler, a US health service physician who would later be part of the notorious Tuskegee syphilis study in Alabama in the 1960s.|date=1 October 2010|author-link=Chris McGreal|archive-date=14 May 2019|archive-url=https://web.archive.org/web/20190514115428/https://www.theguardian.com/world/2010/oct/01/us-apology-guatemala-syphilis-tests|url-status=live}}</ref>
+Similar experiments were carried out in [[Guatemala]] from 1946 to 1948. It was done during the administration of American President [[Harry S. Truman]] and Guatemalan President [[Juan José Arévalo]] with the cooperation of some Guatemalan health ministries and officials.<ref name=CDCFactScheet>{{cite web |title=Fact Sheet on the 1946-1948 U.S. Public Health Service Sexually Transmitted Diseases (STD) Inoculation Study |url=https://www.hhs.gov/1946inoculationstudy/factsheet.html |publisher=U.S. Department of Health and Human Services |date=n.d. |access-date=15 April 2013 |archive-url=https://web.archive.org/web/20130425164618/http://www.hhs.gov/1946inoculationstudy/factsheet.html |archive-date=25 April 2013}}</ref> Doctors infected soldiers, prostitutes, prisoners and [[mental patient]]s with syphilis and other [[sexually transmitted infection]]s, without the [[informed consent]] of the subjects and treated most subjects with [[antibiotic]]s. The experiment resulted in at least 83 deaths.<ref name="BBC20110829">{{cite news |url=https://www.bbc.co.uk/news/world-latin-america-14712089 |title=Guatemalans 'died' in 1940s US syphilis study |date=29 August 2011 |work=[[BBC News]] |access-date=29 August 2011 |archive-date=1 December 2019 |archive-url=https://web.archive.org/web/20191201011231/https://www.bbc.co.uk/news/world-latin-america-14712089 |url-status=live}}</ref><ref name=PHR>{{cite journal |last=Reverby |first=Susan M. |title=Ethical Failures and History Lessons: The U.S. Public Health Service Research Studies in Tuskegee and Guatemala |journal=Public Health Reviews |date=3 June 2012 |volume=34 |issue=1 |article-number=13 |doi=10.1007/BF03391665 |doi-access=free}}</ref> In October 2010, the U.S. formally apologized to Guatemala for the ethical violations that took place. Secretary of State [[Hillary Clinton]] and Health and Human Services Secretary [[Kathleen Sebelius]] stated "Although these events occurred more than 64 years ago, we are outraged that such reprehensible research could have occurred under the guise of public health. We deeply regret that it happened, and we apologize to all the individuals who were affected by such abhorrent research practices."<ref name=NPRapology>{{cite news |first=Scott|last=Hensley|title=U.S. Apologizes For Syphilis Experiments in Guatemala |url=https://www.npr.org/blogs/health/2010/10/01/130266301/u-s-apologizes-for-medical-research-that-infected-guatemalans-with-syphilis |work=[[National Public Radio]] |date=1 October 2010 |access-date=1 October 2010|archive-url=https://web.archive.org/web/20141110013859/http://www.npr.org/blogs/health/2010/10/01/130266301/u-s-apologizes-for-medical-research-that-infected-guatemalans-with-syphilis|archive-date=10 November 2014}}</ref> The experiments were led by physician [[John Charles Cutler]] who also participated in the late stages of the Tuskegee syphilis experiment.<ref name=guardian>{{cite news|first=Chris |last=McGreal|author-link=Chris McGreal|title=US says sorry for 'outrageous and abhorrent' Guatemalan syphilis tests|url=https://www.theguardian.com/world/2010/oct/01/us-apology-guatemala-syphilis-tests|access-date=2 October 2010|work=[[The Guardian]]|quote=Conducted between 1946 and 1948, the experiments were led by John Cutler, a US health service physician who would later be part of the notorious Tuskegee syphilis study in Alabama in the 1960s.|date=1 October 2010|archive-date=14 May 2019|archive-url=https://web.archive.org/web/20190514115428/https://www.theguardian.com/world/2010/oct/01/us-apology-guatemala-syphilis-tests|url-status=live}}</ref>
 ===Names===
-Syphilis was first called ''grande verole'' or the "great pox" by the French. Other historical names have included "button scurvy", sibbens, frenga and dichuchwa, among others.<ref name=Grauer2011>{{cite book |last1=Grauer |first1=Anne L. |title=A Companion to Paleopathology |date=2011 |publisher=John Wiley & Sons |isbn=9781444345926 |url=https://books.google.com/books?id=oztEGntPsFgC&pg=PT643 |page=643|access-date=23 August 2020 |archive-date=11 January 2022 |archive-url=https://web.archive.org/web/20220111075316/https://books.google.com/books?id=oztEGntPsFgC&pg=PT643 |url-status=live }}</ref><ref>{{cite journal |last1=Tagarelli |first1=A |last2=Lagonia |first2=P |last3=Tagarelli |first3=G |last4=Quattrone |first4=A |last5=Piro |first5=A |title=The relation between the names and designations of syphilis in the 16th century and its clinical gravity. |journal=Sexually Transmitted Infections |date=April 2011 |volume=87 |issue=3 |pages=247 |doi=10.1136/sti.2010.048405 |pmid=21325442|s2cid=19185641 }}</ref> Since it was a disgraceful disease, the disease was known in several countries by the name of their neighbouring, often hostile country.<ref name=pmid24653750/> The English, the Germans, and the Italians called it "the French disease", while the French referred to it as the "Neapolitan disease". The Dutch called it the "Spanish/Castilian disease".<ref name=pmid24653750/> To the Turks it was known as the "Christian disease", whilst in India, the Hindus and Muslims named the disease after each other.<ref name=pmid24653750/>
+Syphilis was first called {{lang|fr|grande verole}} or the "great pox" by the French. Other historical names have included "button scurvy", sibbens, frenga, and dichuchwa, among others.<ref name=Grauer2011>{{cite book |last1=Grauer |first1=Anne L. |title=A Companion to Paleopathology |date=2011 |publisher=John Wiley & Sons |isbn=978-1-4443-4592-6 |url=https://books.google.com/books?id=oztEGntPsFgC&pg=PT643 |page=643|access-date=23 August 2020 |archive-date=11 January 2022 |archive-url=https://web.archive.org/web/20220111075316/https://books.google.com/books?id=oztEGntPsFgC&pg=PT643 |url-status=live }}</ref><ref>{{cite journal |last1=Tagarelli |first1=A. |last2=Lagonia |first2=P. |last3=Tagarelli |first3=G. |last4=Quattrone |first4=A. |last5=Piro |first5=A. |title=The relation between the names and designations of syphilis in the 16th century and its clinical gravity |journal=Sexually Transmitted Infections |date=April 2011 |volume=87 |issue=3 |page=247 |doi=10.1136/sti.2010.048405 |pmid=21325442|s2cid=19185641 }}</ref> Since it was a disgraceful disease, the disease was known in several countries by the name of their neighbouring, often hostile country.<ref name=pmid24653750/> The English, the Germans, and the Italians called it "the French disease", while the French referred to it as the "Neapolitan disease". The Dutch called it the "Spanish/Castilian disease".<ref name=pmid24653750/> To the Turks it was known as the "Christian disease", whilst in India, the Hindus and Muslims named the disease after each other.<ref name=pmid24653750/>
-{{Clear}}
 ==References==
-{{reflist}}
+{{Reflist}}
 ==Further reading==
-* {{cite journal |vauthors=Ghanem KG, Ram S, Rice PA |title=The Modern Epidemic of Syphilis |journal=N. Engl. J. Med. |volume=382 |issue=9 |pages=845–854 |date=February 2020 |pmid=32101666 |doi=10.1056/NEJMra1901593 |s2cid=211537893}}
+* {{Cite journal |vauthors=Ghanem KG, Ram S, Rice PA |date=February 2020 |title=The Modern Epidemic of Syphilis |journal=N. Engl. J. Med. |volume=382 |issue=9 |pages=845–854 |doi=10.1056/NEJMra1901593 |pmid=32101666 |s2cid=211537893}}
-* {{cite journal |vauthors=Ropper AH |title=Neurosyphilis |journal=N. Engl. J. Med. |volume=381 |issue=14 |pages=1358–1363 |date=October 2019 |pmid=31577877 |doi=10.1056/NEJMra1906228 |s2cid=242487360}}
+* {{Cite journal |last1=Pastuszczak |first1=M. |last2=Wojas-Pelc |first2=A. |year=2013 |title=Current Standards for Diagnosis and Treatment of Syphilis: Selection of Some Practical Issues, Based on the European (IUSTI) and U.S. (CDC) Guidelines |journal=Advances in Dermatology and Allergology |volume=30 |issue=4 |pages=203–210 |doi=10.5114/pdia.2013.37029 |pmc=3834708 |pmid=24278076}}
+* {{Cite journal |vauthors=Ropper AH |date=October 2019 |title=Neurosyphilis |journal=N. Engl. J. Med. |volume=381 |issue=14 |pages=1358–1363 |doi=10.1056/NEJMra1906228 |pmid=31577877 |s2cid=242487360}}
 ==External links==
-{{offline|med}}
+{{Offline|med}}
 {{Sister project links|display=Syphilis}}
 <!-- ===========================({{NoMoreLinks}})===============================
@@ Line 237: / Line 239: @@
 |  See [[Wikipedia:External links]] and [[Wikipedia:Spam]] for details.
 ===========================({{NoMoreLinks}})=============================== -->
-*[https://www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm "Syphilis - CDC Fact Sheet"] [[Centers for Disease Control and Prevention]] (CDC)
+* [https://www.cdc.gov/std/Syphilis/STDFact-Syphilis.htm "Syphilis - CDC Fact Sheet"]—[[Centers for Disease Control and Prevention]] (CDC)
-*[http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 UCSF HIV InSite Knowledge Base Chapter: Syphilis and HIV] {{webarchive |url=https://web.archive.org/web/20130120002214/http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 |date=20 January 2013}}
+* [http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 UCSF HIV InSite Knowledge Base Chapter: Syphilis and HIV]; {{webarchive |url=https://web.archive.org/web/20130120002214/http://hivinsite.ucsf.edu/InSite?page=kb-05-01-04 |date=20 January 2013}}
-*[https://www.cdc.gov/std/syphsurvreco.pdf Recommendations for Public Health Surveillance of Syphilis in the United States]
+* [https://www.cdc.gov/std/syphsurvreco.pdf Recommendations for Public Health Surveillance of Syphilis in the United States]
-*{{cite journal |last1=Pastuszczak |first1=M. |last2=Wojas-Pelc |first2=A. |title=Current standards for diagnosis and treatment of syphilis: Selection of some practical issues, based on the European (IUSTI) and U.S. (CDC) guidelines |journal=Advances in Dermatology and Allergology |volume=30 |issue=4 |pages=203–210 |year=2013 |pmc=3834708 |pmid=24278076 |doi=10.5114/pdia.2013.37029}}
 {{Medical condition classification and resources

Syphilis: Difference between revisions

Latest revision as of 09:32, 7 November 2025

Contents

Signs and symptoms

Primary

Secondary

Latent

Tertiary

Congenital

Cause

Bacteriology

Transmission

Diagnosis

Blood tests

Direct testing

Prevention

Vaccine

Sex

Congenital disease

Screening

Treatment

Historic use of mercury

Early infections

Late infections

Jarisch–Herxheimer reaction

Pregnancy

Epidemiology

History

Origin, spread and discovery

Arts and literature

Tuskegee and Guatemala studies

Names

References

Further reading

External links

Navigation menu

Syphilis: Difference between revisions

Latest revision as of 09:32, 7 November 2025

Signs and symptoms

Primary

Secondary

Latent

Tertiary

Congenital

Cause

Bacteriology

Transmission

Diagnosis

Blood tests

Direct testing

Prevention

Vaccine

Sex

Congenital disease

Screening

Treatment

Historic use of mercury

Early infections

Late infections

Jarisch–Herxheimer reaction

Pregnancy

Epidemiology

History

Origin, spread and discovery

Arts and literature

Tuskegee and Guatemala studies

Names

References

Further reading

External links

Navigation menu

Search