White Coat Underground

All this talk of Lyme disease is getting me all excited about spirochetes. Borrelia burgdorferi, the bacterium that causes Lyme disease, is a spirochetal bacterium, and so is Treponema pallidum, the spirochete that causes syphilis. Now, if you’re thinking syphilis is all about sores on the naughty bits, you’re missing the best parts of the story. Syphilis is a rather serious and common disease, and can increase the transmission of other STD’s such as HIV. If left untreated it can be disabling and deadly.

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Treponema pallidum, the bacteria that causes syphilis. How cool is that? (courtesy the CDC)

T. pallidum cannot be cultured outside of the human body. That means unlike Strep, for instance, we can’t just grow it in the lab and watch what it does. Much of our knowledge of the disease was acquired during the pre-antibiotic era and from the infamous Tuskegee Syphilis Study.

Anyway, the disease we call syphilis is divided into three stages, each of which is fascinating on its own. In contrast to, say, “chronic” Lyme disease, antibodies can be detected in the blood of people with this disease, and correlate with disease activity.

Primary syphilis

Syphilis is almost always sexually transmitted, and very effectively at that. It causes this lesion, called a “chancre”, which despite it’s horrid appearance is quite painless. These chancres can occur anywhere on the body, and being painless, can hide rather effectively (in the mouth, say). Left untreated, they’ll clear up on their own. This is not a good thing. If penicillin is given at this stage, the infection can be cured. If you simply let your chancre disappear on its own, you’re in a bit more trouble. While the lesion is healing, the spirochete is moving in and finding cozy spots throughout the body.

Secondary syphilis

Weeks to months after the chancre goes away, a new rash may appear (this happens in about a quarter of patients). One of its common characteristics is its appearance on the palms and soles, which is less characteristic of most other rashes. Other symptoms may also appear, such as headache, swollen glands, and fever, but the rash and any other symptoms also disappear on their own. If you once again ignore the illness, you’ve just lost your second opportunity for a cure. At this point, the disease goes into the “latent” phase, and the real fun begins.

Tertiary syphilis

This is some really bad stuff. Tertiary, or “late latent” syphilis can cause an inflammation of the blood vessels leading to among other things deadly aortic valve disorders. More common these days is neurosyphilis, an infection of the central nervous system. This can lead to tabes dorsalis, a disorder of the spinal cord that can be painful and can lead to a severely impaired ability to walk. It also causes “generalized paresis of the insane”. People with neurosyphilis often have a characteristic high-stepping gait, and may become quite demented. (They also have some classic eye findings, but that’s more for pimping med students.) Unfortunately, treatment at this point often does little to reverse the disease, but can halt further progression.

Syphilis is a well-studied disease. There is no vaccine, but it is easily preventable (or would be if we weren’t horny, irresponsible mammals). It’s also easy to cure, if caught relatively early. If it’s not caught early, the patient becomes very interesting, and no one wants to be an interesting patient.

Comments

#1 Whitecoat Tales
May 6, 2009

I saw a patient with neurosyphilis in september. It was a really sad story – pt also had severe RA, not very mobile, so alot of the neurologic signs were missed, she presented with what looked like dementia.

We ended up getting an MRI, saw the demyleination, questionable meningeal inflammation. A little bloodwork later, and we had the diagnosis.

Incidentally, at least in my institutions area, syphilis is making a big comeback among the elderly: They’re having more sex than they used too and not using condoms.
#2 Dr Jim
May 6, 2009

My father used to be a marine fisheries researcher in East Africa in the 70s, and he used to have several tales of various men the research company employed, as labourers, who were turned out to have tertiary syphilis. One incident involved all the young researchers being chased around the research ship by a syphilitic cook wielding a meat cleaver, on each circle of the boat picking up their pieces of scuba equipment before finally jumping overboard.

Quite a feat for a small little spirochete.
#3 Rogue Epidemiologist
May 6, 2009

The comeback we’ve seen is in the MSM population. Incidence was down to almost nothing, and BOOM! A few circuit parties put syphilis back on the map.

Google Image Search for “kissing chancres” if you need to induce emesis
#4 Dacks
May 6, 2009

So, is there any plausibility to the idea that chronic Lyme is a delayed manifestation of disease, a la syphilis? Not knowing much about these nasty bacteria, I don’t know how to judge whether there is any real controversy in these cases.
#5 PalMD
May 6, 2009

the diff is that in syphilis, the organism can be isolated from lesions, and during latent infection, the antibodies are easily detected in the blood.

In so-called chronic lyme, antigen is rarely present unless people use un-validated testing procedures. Antibodies are frequently detectible an anyone who lives in an endemic area and do not correlate with active disease.
#6 Kathleen M. Dickson
May 6, 2009

This writer knows *nothing* about spirochetal diseases. The data he is giving about Lyme is about 30 years old and was debunked by Allen Steere himself at the 1994 FDA Vaccine Committe meeting. I suggest the writer get those transcripts.

Kathleen M. Dickson
http://www.actionlyme.org
#7 PalMD
May 6, 2009

Yo, drive-by…would you care to be more specific?
#8 Tsu Dho Nimh
May 6, 2009

I remember a patient who was admitted with a spectacular secondary syphilis rash.

It was about the only time I saw interns and residents fully complying with the isolation protocol.
#9 Dr Jim
May 7, 2009

@ Drive-by Dickson

History of drive-by….but as I hate ad hominem arguments, I’ll go on.

I’m not sure I understand your advice?

Are we to take it that because PalMD has said something about Lyme disease that you disagree with, we are to therefore believe he knows “*nothing*” about spirochetal diseases? As if they are all the same? I don’t follow your logic.

…and what of Allen Steere? Citing transcripts of a conference is not actually the best way to make a scientific point. As learned as any individual may be, the position of knowledge on any disease is governed by the scientific consensus, which is a product of peer review.

In any case, I’ve read nothing in this blog that seems particularly at odds with Steere’s work. Steere has said himself that Lyme disease is overdiagnosed and overtreated.

In fact the one statement about Lyme Disease in this post (a post about Syphilis), “In contrast to, say, “chronic” Lyme disease, antibodies can be detected in the blood of people with this disease, and correlate with disease activity.”, is a position that Steere agrees with.
#10 Ramel
May 7, 2009

It amazes me that syphilis is still so prevelent given the relitive ease with which it can be controlled, is this a public education problem?
#11 David
May 7, 2009

The eye findings of neurosyphillis once led me to the diagnosis (during a neurology consult) in a patient hospitalized on a psychiatry ward for atypical mania.
#12 Dave Ruddell
May 7, 2009

It causes this lesion, called a “chancre”

Dude, how about a NSFW warning!?
#13 PalMD
May 7, 2009

well, at my work, it IS safe : )
#14 Igor
May 7, 2009

I doubt you’re going to get anything more specific or even more coherent from your drive-by. I checked out the promoted website and it’s a mother load of all incoherent conspiracies.
#15 merlyn mencke
May 7, 2009

Why is it that antibodies can not be found in ‘chronic lyme ” but the spirochette can be detected by PCR.
#16 PalMD
May 7, 2009

Why are you assuming facts not in evidence?
#17 daedalus2u
May 7, 2009

You should have mentioned that the first effective treatment for tertiary syphilis was fever therapy. That is infecting a patient with malaria, letting them go through ~10 cycles of fever before curing it with quinine. The originator won the Nobel Prize (well deserved) and it was the “standard of care” for neurosyphilis for a couple of decades before penicillin was developed. When penicillin was available, at first the docs, conservative practitioners that they were did both, first used a course of penicillin, then a course of fever therapy. It was only after there were some trials without fever therapy that it was abandoned. Fever therapy was a harsh treatment with a lot of side effects and not a small death rate (~10%). It was used to treat neurosyphilis which was virtually 100% fatal, and let people in some cases resume pretty normal lives.

I think neurosyphilis does look a lot like what is called chronic Lyme. I think that any type of chronic neuroinflammation will cause much the same symptoms, the paralysis of tertiary syphilis, the brain fog of chronic fatigue syndrome, the dementia of Alzheimer’s. All of them will show white matter hyperintensities on MRI. I think this is due to low ATP in the neurons reducing the intracellular transport by ATP powered motors up and down the axons. With less ATP there is less movement and less entrained water which shows up as reduced “diffusion” on MRI. It isn’t just “diffusion”, but any movement of water that shows up.

Fever therapy was used a lot for other neurological disorders too. I blogged about it in the context of autism. There was a report that acute fevers did temporarily improve some behaviors of autism, my hypothesis is that the restoration is due to NO from iNOS. I think that is the same mechanism by which fever therapy resolved neurosyphilis.
#18 Mu
May 7, 2009

Quote from your drive-by’s website

INTRODUCTION to CRYME DISEASE or Slut-Central; Corrupticut, where criminality and whoredom is admired, promoted, protected and respected.

Makes you wonder if the writer is at the tertiary stage herself.
#19 Eric Jackson
May 7, 2009

Wow. This got far more attention over here than it did at SBM. A veritable foaming rant on the other thread.

Unfortunately, the raving drive-by site is rather typical in theme and content, if probably a bit further off the deep end than most. And when the bus for a particular topic is making regular stops in tinfoil town, it’s the sort of thing that’s going to drive a lot of legitimate research off the bus.

I’d also like to note that the PCR testing for Borrelia DNA has about a one in three chance of false positive. It also requires that a tissue sample be taken and cultured in one of the medias Borrelia can grow in.
#20 sam
May 8, 2009

Way back in my sex, drugs, + rock n roll days, I got the syph. No symptoms, as far as I knew. Never even saw the canker sore, which seems a little weird given the description here.
questions for a doctor: back in the promiscuous circles I was in, there was a common belief that you didn’t need to worry about syphilis (like, getting tested for it), because if you were sleeping around enough to get syphilis, you would almost certainly have gotten gonorrhea and/or chlamydia too, and those are diseases that are pretty easy to notice (burning piss and nasty genital excretions tend to bring a person to the VD clinic). People said that the antibiotics they gave you for the clap would also wipe out the syphilis, so you didn’t need to worry about it. The saying went, if you haven’t had the clap, you weren’t having enough sex to get syphilis, and if you did have the clap, you were already treated for syphilis! I can’t even tell you how many times I have heard this, so I’m dying to know if it’s true, or just an urban myth.
Is it more difficult/expensive to test for syphilis than other VDs?
The VD clinic where I lived used to do chlamydia/gonorrhea for everyone all the time, plus some tests + exams specific for women, but syphilis was never a priority – they’d give a syphilis test only when someone was repeatedly positive for other VDs, or, I presume, if the person had obvious symptoms or had a lover who they knew had it. I think back then, there wasn’t a herpes test and even if someone had obvious herpes, there wasn’t anything they could give you for it. After the hive came along, syphilis seemed to become even less of a priority. Once the HIV test was invented, they were giving that to everyone, and only gave the syphilis test if you were positive for HIV. That’s how I found out about the syph. I couldn’t have had it for too long, though, because I never had symptoms.
It seems kind of weird, though. Everyone always talks about HIV being less easy to pass on than other VDs, so wouldn’t there be a lot of people who might have syphilis but not HIV? I guess, though, when you’re dealing with limited funds, you do what you can.

I’m writing on this blog anonymously, but in general, I have no difficulty admitting my HIV status. There’s just something weird about syphilis – I’d feel far more embarrassed to admit syphilis. I feel like it’s got the worst stigma of all the VDs, and I’m not really sure why, since it’s so treatable.

Oh, another question: I actually heard from someone that they still cure basic syphilis with a single shot of penicillin. I’m just curious, because it seems like every other bug under the sun gets resistant to drugs in a flash, how come syphilis hasn’t managed to evolve some resistance to penicillin? (assuming that what I heard is correct)
#21 Zetetic
May 8, 2009

I’m not an MD but I have extensive public health and laboratory experience. Quick screening tests for both “Clap” and syphilis are easy and quick. There was a time, not too long ago and because of major public health preventive initiatives, when syphilis was relatively rare and not the first thing thought of when testing for STDs. Antibiotic resistance can be an issue with both organisms. I recall during my Army Medic days in Korea that we gave as much as twice the usual U.S. mainland dose of Bicillin LA to syphilis victims.
#22 catgirl
May 12, 2009

It amazes me that syphilis is still so prevelent given the relitive ease with which it can be controlled, is this a public education problem?

Part of it is a lack of education, and part of it is the shame that our society has about STDs. A lot of people don’t have the education to recognize it, and a lot of people are too embarrassed to bring it up with their doctor or other sex partners.
#23 killer bee
June 22, 2010

to the doctors specialized in syph: i got a friend before, he has a syph on findings on his medical record, and a ratio of 1:14,but he admitts he does not have any complications in his body not a single spots or anything, he undergo for the medications and shot of antibiotics and penicillin, after that he’s ratio is 1:4, is he cured for the rpr result or is he cleared for the result coz everytime he check on his rpr got a ratio of 1:4, does he continoue his medication or is there any possibilities that it would be a neagative on that test for the rpr? he admits on me that he want to work abroad, i help him a lot for the possible answers i could get for him and uplift his confidence to get a work. is there any chances that if he continous his shots/medication does he could have a negative result on syph rpr testing? please i need your answer… thanx!