Background: Syphilis is a treatable bacterial infection caused by Treponema pallidum. There has been a change in incidence of syphilis in various nations over the years. Aim: To study the epidemiological trends, demographic profile, high-risk behaviour, clinical pattern, and stage of syphilis over the last ten years in patients presenting to an STD clinic in a tertiary care hospital. Material and Methods: This was a retrospective observational study over ten years. Records of all confirmed syphilis cases were analysed in relation to demography and clinical profile. Results: There were a total of 3,110 STD patients among whom 31 cases (accounting for 0.99%) of confirmed syphilis were seen. There was a significant increase in cases in the last five years of study, especially in the last year. An increase in primary (PS) and secondary syphilis (SS) was observed. Males outnumbered females (3:1). Mean age of patients was 35.0 ± 11.53 years. Professionals were most common (22.6%) having syphilis followed by farmers (19.35%). A significant proportion (45.1%) of our patients were at least graduates. Unprotected sex was seen in all the patients followed by extramarital/premarital sex (71.35%). There were 16.12% of cases who had a history of paid sex and 9.7% were homosexuals. SS and latent syphilis were more common (38.7% each) than PS (19.35%). In PS single chancre and in SS truncal asymptomatic rash was the commonest clinical presentation. Limitation: Single-centre study, including only self-reported patients leading to a small sample size, is the major limitation of the study. Conclusion: The increased trend of primary and secondary syphilis in recent years highlights that there is a risk of an impending epidemic.
Keywords: High-risk behaviour, latent syphilis, primary syphilis, secondary syphilis, syphilis
Syphilis is a multisystemic bacterial infection caused by a spirochete Treponema pallidum. A great imitator due to its protean presentations in different organ systems, it can mimic a number of common and rare diseases. Syphilis was described in the late fifteenth century and has plagued society time and again ever since. Syphilis patients may be symptomatic in primary, secondary disease and also in the tertiary stage of late syphilis but there is no clinical evidence of disease in the latent phase (hidden phase) There was globally a sharp decline in the incidence of disease in 1990 which was explained by the fact that due to HIV pandemic, patient started practicing safer sex.[1] But it has again re-emerged as an endemic disease among many developed nations like the USA, Canada, and Australia especially among males having sex with males (MSM).[2],[3],[4]
Our state is a small hilly state in northern India with a population of 7,394 million. The prevalence of HIV in our state in 2016 was 0.12% (in contrast to national average of 0.22%). Syphilis accounted for 0.49% of total STD cases in India and 0.37% in Himachal Pradesh.[5] There are 20 designated sexually transmitted infection (STI)/reproductive infection (RTI) clinics (DSRC) in the state. Study population comprised of cases in a single DSRC which usually caters to patients from the attached dermatology and venereology clinic in a tertiary care centre. This study was conducted to observe the change in number of cases over the years, demographic profile, high-risk behaviour, clinical pattern, and stage of syphilis.
Material and MethodsOur study was a retrospective observational study done over 10 years from July 2012 to June 2022. Ethics Committee approval and patient consent were taken. All cases suffering from sexually transmitted diseases (STD)/those found positive on testing before blood donation presenting to our DSRC are routinely registered in our clinic, and after informed consent, the demography, sexual practices, and high-risk behaviour (and clinical details of the patient are observed and entered in a predesigned proforma. In addition to other bedside tests, serological tests for syphilis and HIV are done as per the NACO (national AIDS control organization) guidelines after pretest counselling. Screening with non-treponemal test (rapid plasma regain (RPR) is done using an RPR kit manufactured by Biolab diagnostics, Tarapur. In all the cases found positive on screening, the titre is determined and a confirmatory treponemal pallidum haemagglutination (TPHA) test manufactured by Omega diagnostics is done, hence ruling out the false positive RPR.[6] HIV testing is done as per standard method using Comb-AIDS immunodot test for HIV 1 + 2 provided by NACO, India. All the information thus gathered is kept confidential. Post-test counselling is routinely done.
The records of all registered STI cases between July 2012 and June 2022 (ten years) who tested positive for syphilis were included in the study. Demographic details (gender, home location, marital status, occupation, and education) of these patients were observed. The type of high-risk behaviour (unprotected sex, multiple sexual partners, contact with commercial sex workers, history of spouse having STI, premarital/extramarital contact) of these patients was recorded. Clinical details like the signs and symptoms, duration of disease, and stage of syphilis were recorded. The presence of other associated STIs if present was noted. Staging of syphilis was done according to NACO guidelines.
Statistical analysis was done using Epi info 7.2.2. All categorical variables were expressed as percentages or proportions and comparisons were made using the Chi-square test or Fisher's exact test, as appropriate. Continuous variables were presented in mean ± SD. Variables identified as clinically significant at the univariate level (p < 0.05)
ResultsThe study comprised of 3,110 patients of STI, out of which confirmed syphilis was seen in 31 (0.99%) cases. As can be seen in [Table 1], there was an increased number of syphilis cases from 2017 onwards to reach a significant increase in the last year of study (though there was no case during the peak of COVID). While there were only six cases (19.3%) in first half of the study, 25 cases (81.7%) were seen in later half of the study. Primary and secondary cases were significantly more (p < 0.05) in second half of the study.
Demographic, clinical features and laboratory parameters of the patients are as mentioned in [Table 2]. The mean age of the patients in our study was 35.0 ± 11.53 years with a median age of 36 years. The commonest age group involved was 20–30 years (32.1%) followed by 31–40 years and 41–50 years (22.6% in each group). The youngest was a teenager aged 16 years (case no. 15 [Table 2]). Male female ratio was 3:1. There were 80.65% patients who were married. Of these married patients, 52% had extramarital sexual contact. There were 19.3% of cases who were unmarried and had premarital contact. A high percentage of our patients were at least a graduate (45.1%) while 6.45% were illiterate. Professionals were the most common occupational group (22.6%) involved followed by farmers (19.35%) and housewives (16.1%). There were 9.7% students while there were no sex workers in our study.
Table 2: Demographic and clinical manifestations of confirmed syphilis casesThe mean duration of high-risk sexual contact was 2.59 ± 2.33 months. Unprotected sex was the most common high-risk behaviour seen in all the patients. Extramarital and premarital sex was practiced by 61.2% of people. Paid sex and MSM were seen in 16.12% and 9.7% of patients, respectively. Our patients presented with complaints of STI (41.9%), dermatological complaints (16.12%), a referral from the blood bank (16.1%), an antenatal clinic with/without a spouse (12.9%), gynaecology OPD (6.45%), and ART centre (3.22%) and one patient required medical fitness certificate (3.22%). Associated STI was seen in 14 patients (45.16.9%) among whom four (12.9%) had HIV (human immunodeficiency virus) positivity. Secondary syphilis (SS) and latent syphilis (LS) were seen in 12 (38.7%) patients each while primary syphilis (PS) was seen in six (19.35%) patients. There was one patient who had both PS and SS, this patient also had HIV infection (case no. 20 [Table 2]). In addition to this HIV, positivity was seen in two patients of SS and one of LS [Figure 1] and [Figure 2]. In PS, single chancre was found in four patients, multiple in three patients, and localized lymphadenopathy (LAP) was seen in four patients while generalized LAP in a patient who had both PS and SS. However, the remaining two patients had no involvement of lymph nodes. SS patients had maculopapular and papulosquamous lesions on the trunk in 7, mucous patches in 5, palmoplantar syphilide in five patients, and pigmentation on palms and soles in one patient [Figure 3], [Figure 4], [Figure 5], [Figure 6]. Scrotal plaques were seen in three patients. In SS, generalized LAP was seen in seven patients while six patients had no LAP. There was no case of tertiary/neurosyphilis in our study. The median RPR titre was 1:64 and median TPHA was 1:128. In two patients (number 25 and 26), initial RPR result was negative but as we strongly suspected syphilis so a repeat RPR in dilution was done and found to be positive, one of these patients was HIV positive.
Among graduates, 11 presented as PS/SS and only 3 had LS, while lesser educated/illiterate patients had PS/SS in eight cases, whereas LS was seen in nine cases. Most of the professionals presented with early symptomatic syphilis (six early symptomatic vs one LS) while among housewives LS was more (one early symptomatic vs 4 LS) and farmers (two early symptomatic syphilis vs 4 LS). All the students presented with early symptomatic syphilis. Unmarried patients presented with either PS/SS, while, among married, 52% were in symptomatic stages and 48% in LS.
DiscussionSyphilis is a preventable disease, which can be diagnosed with the help of a detailed sexual, and systemic history along with the clinical examination and confirmed by commonly available serological tests. If timely diagnosed in early stage syphilis can be treated, the stigmatic and incapacitating features be avoided and transmission decreased. But in spite of this, globally seven million new cases of syphilis were diagnosed in 2020 (even during COVID pandemic).[7] Melody Ren et al.[8] observed that there is globally a reversal of decreasing incidence to an epidemic with a growing phase. WHO has set a target for reducing the incidence of syphilis by 90% but with the present burden and reappearance of syphilis this goal seems to be a Herculean task.[9]
In developed countries, there are various population-based studies that have observed an increase in syphilis cases, especially among the high-risk population, e.g., in MSM, sexual health workers, etc.[8] In developing countries, it is suspected that the prevalence of syphilis is higher even among the general population.[8] The national average of syphilis in 2019 was reported as 0.49%.[5] There are multiple studies that have been conducted in different parts of our country and the neighbouring countries, but most of them like the present study are single-centre studies.[10],[11],[12],[13],[14],[15],[16],[17] The comparison of results of a few studies with our study is as shown in [Table 3] and [Table 4].
Table 3: Table showing a comparison of demographic, high-risk behaviour, and prevalence in the present study with various other studiesTable 4: Comparison of clinical manifestations and serological tests of our study to various studiesSimilar to our study, a rising trend (0.49% to 4.41%) has been observed by Sethi et al.,[18] Thokchom et al.,[19] and Sivayadevi.[15] Rajakumari et al.[20] at Madurai, Tamil Nadu, reported 12 cases in a short span in the year 2018. Kulkarni et al.[21] reported 36 cases in just 16 months from Pune. Nishal et al. observed a decreasing trend of syphilis from 2008 to 2012. Nishal et al.[10] also observed a significant increase in a number of latent syphilis cases, while there was no significant rise in primary and secondary syphilis cases over the year. The meteoric rise in syphilis cases whether it is actually there or just apparent is not clear. The increase in the number of cases can be attributed to better access to medical facilities, increase IEC (information, education, and communication) activities along with the contribution of social media to promote awareness about the clinical manifestations of the disease. Also, there may be a true rising trend because of liberal sexual behaviour norms, availability of sex networks, and the easy availability of pornographic films on social media.[22]
The incidence of syphilis in our study as shown in [Table 3] is comparable to Sivayadevi et al., whereas it is very less as compared to other studies.[10],[11],[12],[15] This can be attributed to decreased referral from other health facilities and a separate antenatal and gynaecological centre in our set-up. Also, the absence of self-reporting of sex workers in our study was seen, which points to our inadequate efforts to reach these high-risk groups and overcome the social stigma.
Male preponderance and peak in reproductive age groups are similar to most of the other studies [Table 3].[10],[11],[12],[13],[14],[15],[16],[17] More practice of unsafe sex and high-risk behaviour by males predisposes them for acquiring syphilis.
A high percentage (45.1%) of our patients were graduates which were in concordance with a study by Jain et al.[12] where 80% of cases were literate. This can be attributed to a better understanding of the gravity of the problem by literate, hence educated and professionals seek medical advice earlier. Students who want to explore new activities and with a lack of proper knowledge get involved in high-risk sexual behaviour.
Patients practicing extramarital sex (EM) in our study were comparable to most of the studies [Table 3].[10],[11],[15] Furthermore, these patients presented more commonly with symptomatic syphilis. In this study, the number of MSM was relatively less than in other studies; however, all the MSM reported in the last year of our study highlighted the increased awareness among homosexuals.[11],[14]
A relatively lower number of patients with PS were seen in contrast to most of the studies [Table 4]. Jain et al.[12] reported PS in 46% of cases. The lower incidence of PS in this study can be explained because difficult terrain patients do not seek medical advice at a tertiary care hospital for initial manifestation. Symptomatic syphilis was seen in 61.3% of patients similar to most of the studies. A higher incidence of latent syphilis was observed by Wahab et al.[13] and Sivayadevi et al.[15] Arando et al.[23] studied syphilis at a centre in Barcelona, Spain, in 270 cases among whom the majority (99.1%) were MSM and observed PS in 27.7% and SS in 51.1%. Cases of primary and secondary syphilis may be a sign of an impending epidemic. The reproductive rate (R) of a sexually transmitted infection = average rate of exposure X average likelihood of infection (33% in syphilis) × duration of infectiousness (about 2 years in untreated syphilis).[24] Average rate of exposure is directly proportional to a number of infected partners, especially in early/symptomatic stages of syphilis R >1, which indicates increase in incidence.[25]
In PS, single chancre was more commonly seen than multiple, only three patients had multiple chancres of which one of them had coexisting SS (telescoping of syphilis stages) and HIV. The number of multiple chancres in our study is more than other studies.[14],[15],[19]
In SS, involvement of the palms and soles was seen in 46.1% of patients. Similarly, Sivayadevi et al.[15] reported palmoplantar involvement in 52.6% of cases. This highlights the importance of examining palms and soles in every case of STD. Oral mucosal involvement in our study was seen in a significant number (38.4%) of patients which is much higher than the 6.4% and 2.6% mucosal involvement seen by Shah et al.[14] and Sivayadevi et al.,[15] respectively. Truncal rash was seen in 53.8% of our patients similar to Nishal et al.[10] and Jain et al.,[12] where around 54% had truncal rash. Condylomata Lata was not seen in any of our patients. Generalized LAP was seen in 61.5% of our patients, whereas a higher rate of lymph node involvement was observed by Jain et al. (90%) and Nishal et al. (86.8%).
Syphilis HIV co-infection was observed in 12.9% of our patients similar to Nishal et al. High-risk behaviour, breech in the mucosa, and mucosal inflammation predispose syphilitic patients to HIV infection.
Syphilis diagnosis may be usually missed or delayed due to multiple reasons. These cases present with heterogenous manifestations not only to venereologists but to other medical and surgical specialties where due to a low index of suspicion they are not serologically tested and diagnosed. Delays may also occur at the patient's end for fear of the judgemental attitude of health care providers, self-medication by patients, and social stigma. Also due to the non-problematic nature and non-persistent nature of various clinical features, patient has a false impression that they are disease free and hence continue transmitting the infection. Due to the involvement of non-reproductive organs, patients believe that their disease is not sexually transmitted. Visit to a non-registered medical professional and syndromic management adds to decreased notification of syphilis, All these lead ultimately to underreporting of disease. So even the small numbers of syphilis patients in our study should be considered a tip of the iceberg. Lack of adequate and timely treatment may ultimately lead to tertiary syphilis, recurrence of the highly infective phases, and also continuous transmission of infection. Scaling up the case finding in the early phases is the need of the hour. A high index of suspicion, a rapid card test for screening, and sensitizing the other medical fraternity about the disease is of utmost importance.
ConclusionThe re-emergence of early syphilis cases in different parts of India highlights that we still have to be vigilant and have an eagle's eye and a high index of suspicion to achieve the goal set by WHO. The effective control of syphilis remains a formidable challenge and can be achieved by early diagnosis, treatment, and contact tracing
Limitations: Since it is a single-centre study that too of self-reported people and the sample size is less, true situation in the community cannot be calculated and compared in various geographical regions and various population groups. Also, this is a retrospective study over the past 10 years so individual observer variation cannot be ruled out. The lack of follow-up is another limitation of the study.
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Conflicts of interest
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References
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