Neapolitan soldiers, awash in pustules and
pain, labeled it mal franzoso, "the French disease," in 1495.
Their French opponents, stricken from king to foot soldier, called it
"the Neapolitan disease."
As the sickness spread through Europe, so did
the finger-pointing. Russians dubbed the ailment "Polish sickness."
Poles attributed it to Germany. By 1515, the plum-colored sores, which
one poetic chronicler likened to upturned flowers, had bloomed on bodies
in Japan. The Japanese wasted no time in naming them "Chinese ulcers."
Syphilis, for centuries so feared that it was
known as the "great" (as opposed to the small) pox, has been distinguished
as much by the desire to blame it on others as for its power to destroy.
Medieval cities banished syphilitics outside their gates or "cured"
them with mercury ointments that made their bodies shake and teeth fall
out before they died. In the U.S., well into the 20th century, syphilitics
were subject to toxic treatments both physical and moral: expensive,
ineffective drugs as well as public condemnation as "plague spots" and
infectors of "innocent victims." Those theorizing the origins of syphilis
have pointed to distant continents and unspeakable acts: Columbus' voyage
to America, government conspiracy (Spaniards, it was said, mixed lepers'
blood with Greek wine), or those perennial favorites -- divine retribution
and sexual unions between man and monkey. Ring a bell?
Today, post-penicillin and in comparison with
AIDS, the great pox seems more like small potatoes. Yet for those wrestling
with HIV, Treponema pallidum -- the corkscrew-shaped bacterium
(spirochete) that causes syphilis -- is both past lesson and present
danger. Over the past two years, outbreaks have been reported in many
urban centers; in virtually all of them, the majority of cases have
been among people with HIV. Syphilis -- or, more accurately, the sores
(called chancres) or rashes it causes in its early stages -- heightens
risk of HIV transmission and may be harder to detect in HIVers. Doctors
have reported cases of syphilis progressing to its fourth, most neurologically
damaging phase (see "The Four Seasons of Syphilis" below) in a matter
of months, as opposed to years, among people with weakened immune systems.
And some pre-HAART era studies have found that having syphilis may be
a cofactor that speeds progression from HIV to AIDS.
or all these reasons, says Dan William, MD,
a longtime AIDS doctor in New York City, it may be time to review the
ABCs of STDs in general, and syphilis in particular. "If we do not learn
the lessons of history," says William, "we may be doomed to repeat them."
If you've had syphilis, you're in distinguished
company: Pope Julius II, Henry VIII, Ivan the Terrible, George Washington
and Nietzsche were all syphilitics. Still, spotting a sore on your vagina,
anus, penis or mouth rarely seems great. "It made me feel dirty," says
Dominic, a New York City writer who, like other syphilis sufferers interviewed
for this article, prefers not to give his last name. "My HIV, which
I've had for years, can seem so nebulous. But seeing that chancre on
my penis, I felt . . . revolted." At the health clinic
where the then-32-year-old went for his diagnosis, he got a whopping
shot of penicillin and a subtle dose of disapproval. "The nurse asked
me if I could give the names of people I'd had sex with," he recalls.
"And there I was, facing the typical urban gay conundrum: Was it Tom,
Dick or Harry? When I told her I didn't know the names of all the possibilities,
I faced all the usual shade aimed at the promiscuous gay male -- clucking
For AIDS advocates, naming names awakens old
fears of a government more interested in containing illness than in
treating it. With syphilis, though, asking for the names of sexual partners
has a human side. Unlike HIV, syphilis can be prevented post-exposure
if you find out quickly enough -- not with toxic drugs of questionable
efficacy, but with a single shot of penicillin. Unlike HIV or herpes,
syphilis can usually be cured if you catch it early. And unlike HIV,
it remains infectious no longer than two years. Since most people are
not "lucky" enough to see a syphilis sore, a little early warning goes
a long way toward epidemic control.
All of which makes health departments across
the country willing to track down as many sexual partners as you'll
tell them about. "We never use your name, and we'll go out looking for
'JB with blond hair,' if we have to," says Peter Leone, MD, medical
director of the Wake County STD clinic in Raleigh, North Carolina. "And
we can draw blood or treat on the spot, for free."
Kelly, now 45, got a health department call at
his job in Salt Lake City, Utah. Recently divorced and still closeted,
he had been finding sex partners in the only place he felt safe looking
-- the local bathhouse. This was early in the AIDS epidemic, and the
health department's call was the first sign he'd had that playing with
men was "real life, not just pure fun." His blood tests (see "Sussing
Out Syphilis" below) showed latent syphilis, so his doctor recommended
a spinal tap to make sure there was no neurological involvement.
The test showed no spinal fluid abnormalities,
so Kelly got rid of his infection with standard treatment for latent
syphilis: injections of penicillin, "once a week for three weeks in
alternate buttocks." But his syphilitic status, however temporary, was
a clue to a more enduring health challenge. "If it wasn't for the syphilis,
I wouldn't have thought about taking an HIV test," Kelly says. "As it
was, I waited a while. Later, my new boyfriend and I both went in. I
was positive. So was he."
Stories like Kelly's and Dominic's have health
care providers "clucking" more loudly at promiscuous gay men of late.
One urban center after another -- Los Angeles, San Francisco, Seattle,
Chicago, San Antonio and Philadelphia -- has reported rates of syphilis
on the rise among gay men. "The present problem is extremely dangerous,"
declared the Seattle and King County Public Health Department, reporting
35 new cases of syphilis among gay men in 1998. In San Francisco, seven
cases in 1999 sparked national headlines. In Los Angeles, where 93 cases
were reported in the first three months of 2000, testing vans rolled
into gay neighborhoods to smear sores or take blood from all comers.
Why the furor? While late-stage syphilis is serious,
or even fatal, it's what syphilis says about HIV transmission that has
health authorities most concerned. Syphilis is transmitted either from
mother to fetus or when broken skin or mucous membranes of the mouth,
anus or vagina come in contact with the sore or rash of someone already
infected. Which means that if you got syphilis, you might have gotten
-- or given -- HIV. And together, the spirochete and the retrovirus
are double trouble. "Syphilis makes HIV transmission significantly easier,"
William says. "If you're HIV infected, a syphilis sore is loaded with
HIV. A syphilis infection can cause a bump in your viral load, which
also makes you more infectious." If you're HIV negative and have syphilis,
the sore can provide HIV with a convenient route of entry.
Deepening health authorities' concern is the
fact that most of the gay syphilis cases were among men who'd met in
bathhouses or through the Internet. For a disease whose control has
traditionally depended on face-to-face contact, the specter of trying
to track down some guy in a cubicle or the man whose screen name is
"dreamdick12," makes finding "JB with blonde hair" look easy. In July,
The Journal of the American Medical Association (JAMA) fueled
the furor with a study announcing that people cruising the Internet
for sex are more likely to have STDs and to have sex with an HIVer.
Others, though, look at the syphilis news and
see an old, familiar problem: a rush to condemn gay sex. If the new
cases of syphilis are among positive men who aren't using condoms with
each other, is that really a marker of new HIV infections? Might increased
rates of syphilis say more about how many people are going to city clinics
than about new infections? Humboldt State University professor Eric
Rofes questions whether "a frenzy of press releases and a melodramatic
response to data trends" helps either gay men or the credibility of
the public health establishment. Gay sexual practices, he notes, are
frequently pathologized, "while parallel practices between men and women
are discussed cautiously and empathetically."
In Seattle, where most men with syphilis are
over 25 and already HIV positive, prevention workers privately question
the wisdom of crying wolf. "These guys have probably heard the old messages,"
says Eric Hildebrandt of the local HIV prevention group Gay City. "Instead
of ringing the alarm bells, we need to be tailoring messages to people's
HIV status and convincing doctors to replace lectures with real education
about how syphilis itself can be dangerous."
As part of this effort, the CDC puts out a national
map of syphilis. Black triangles indicate rates of more than seven cases
per 100,000 people. One look at the map shows that it's not really the
information superhighway that is syphilis' route of choice, but a more
earthbound trail: U.S. Interstate 95. Trace that road down the Eastern
seaboard and you can see the incidence thicken, spreading out around
Baltimore, taking a left at Florida, and fanning out like the roots
of a tree in the rich soil of the Mississippi Delta. One suspects the
triangles' color was not chosen randomly. The places where rates are
highest -- Lancaster, South Carolina; Baltimore, Maryland; Tuscaloosa,
Alabama; Robeson, North Carolina; Davidson, Tennessee -- all include
neighborhoods or farmlands inhabited by poor African Americans.
T. pallidum -- the "pale treponeme" --
is ironically named: African Americans are 34 times more likely to have
syphilis than whites. This fact has political significance, at least
in the eyes of some alarmed by federal reluctance to send syphilis into
history. This year, the CDC asked for a $15 million increase for its
syphilis-elimination campaign; so far, Congress has demurred.
Such Congressional inaction is all the more galling
given syphilis's link to one of our nation's greatest shames: the notorious
Tuskegee study. Begun in 1932, it invited 600 black men in Macon County,
Alabama, to get help for "bad blood," local-speak for ailments ranging
from anemia to syphilis. The men, 399 of whom had syphilis, were offered
free medical exams, free meals and free burial insurance. What they
were not given -- even after penicillin became the standard of care
in the 1940s -- was proper treatment. For 40 years, researchers withheld
care and watched these men waste away, infect their wives and children,
and, in many cases, die. "Tuskegee goes right to the heart of black
people's suspicion that if you go into the health care system, you may
not survive,"says Stephan Oxendine, cochair of San Francisco's Ryan
White Planning Council. "It has become a metaphor for all those times
when we suspect that in the eyes of the U.S. government, African Americans
Sheila, 32, is a Wake County resident who understands
firsthand the value of outreach. "I never heard anything about syphilis
until I was going to get treated," she says. "I had a sore on my leg
-- I'd thought I'd gotten bit by something. A friend said, 'Girl, don't
you know what that is?'" Sheila's positive syphilis test led
her to work up the resolve for an HIV test -- also positive. Nine hospitalizations
later, she's feeling well and volunteering for a Raleigh AIDS organization,
where she folds syphilis into her AIDS talks. "Even with all this emphasis
on HIV, you don't hear much about other STDs," she says. "I honestly
believe that if there had been people out there talking about how to
protect yourself, I would have been safer."
Silence around syphilis, say some researchers,
may extend from the streets to the research lab. Despite widespread
skepticism, they see in syphilis a cofactor or even a cause of AIDS
(see "The Case of the Missing Cofactors," POZ, April 2000). They
point not only to the epidemiological synergy between syphilis and AIDS
-- spikes in syphilis regularly precede new AIDS epidemics worldwide
-- but to the medical literature before the age of antibiotics. "TB,
rare cancers and pneumonias -- all of these were documented, if unusual,
expressions of syphilis before the antibiotic era," says Joan McKenna,
a research physiologist whose 1986 article in the journal Medical
Hypotheses first presented the AIDS-syphilis connection.
McKenna found an unlikely ally in Sandra Larsen,
MD, then a syphilis expert at the CDC. "The clinical manifestations
of syphilis, which have taken various forms over the century, have now
been transformed to mimic the appearance of the opportunistic infections
and cancers that may accompany HIV infection, as well as the clinical
symptoms of AIDS itself," Larsen wrote. McKenna began sending AIDS patients
in for confirmatory syphilis tests, even when they'd first tested negative.
"We had people showing up negative on the initial tests even when they
had known infections and tertiary symptoms," she says. "These syphilis
cases were being missed."
McKenna is now a minister at the Vaca Valley
Church of Science in Fairfield, California ("the same church as Louise
Hay," she notes), and Larsen is retired from the field. Others interested
in the AIDS-syphilis link scrapped the theory in the late '80s, when
doctors treating HIVers with IV antibiotics found that they still sickened
and died. But the idea that a new form of chronic syphilis may be mistaken
for HIV-related infections, has been kept alive by Toronto researcher
John Scythes and colleague Colman Jones. "Repeated studies show that
syphilis infection and, particularly, reinfection, may not be detected
with current tests," Jones says. "So some of those we say are cured
of syphilis may instead be being missed. The CDC estimated there were
325,000 cases of untreated syphilis at the end of the 1970s. Where did
New research into syphilis' suburban cousin --
Borrelia burgdorferi, the spirochete that causes Lyme disease
-- has bolstered the case for better tests. Recently researchers have
successfully cultured B. burgdorferi from the blood of Lyme disease
patients supposedly cured by antibiotics and found a cyst-like form
of the Lyme spirochete, adopted in response to meds, which is often
missed with standard microscopy. Might syphilis similarly adapt to avoid
antibiotics and detection? "There is much we do not yet know," says
Willy Burgdorfer, PhD, the Lyme spirochete's discoverer. "But T.
pallidum does behave in ways very similar to B. burgdorferi."
Eventually researchers may be able to culture
the syphilis spirochete from long-infected patients in the same way
they cultured the Lyme spirochete. In the meantime, a number of companies
are developing assays capable of picking up syphilis that existing tests
miss. "There are many such tests in development," says Robert Baughn,
PhD, of the Department of Microbiology at Baylor College of Medicine
in Houston, Texas: "There's a western blot test, PCR tests that extract
genetic material from the spirochete, as well as a number of tests using
recombinant T. pallidum antigens rather than antigens used by
the standard confirmatory tests." None has yet been approved for clinical
use, though at least one recombinant antigen test, called TrepCheck,
has shown greater sensitivity than standard assays in prelimary research.
Scythes and Jones point to results like this
to emphasize the importance of using treponemal-specific tests for syphilis
and of greater research into spirochete detection and treatment. As
for clinicians on the ground, many acknowledge the shortcomings of current
knowledge, but see the syphilis-as-cause-of-AIDS discussion as a distraction.
"It would be nice to have a more responsive test. But we haven't gotten
the old tests and treatments we already have to people -- positive and
negative -- who can benefit from them," says Leone. "Given all we know,
that's a national tragedy."
History does repeat itself. In this era, though,
it may be that a Congress uninterested in eradicating syphilis, rather
than those who suffer from it, is who is most worthy of blame.
THE FOUR SEASONS OF SYPHILISStage: Primary
Incubation/Infectiousness: Infection occurs when chancre (or its fluid) contacts mucous membranes or from mother-to-fetus. Chancre appears 10-90 days after contact.
Symptoms: Painless chancres usually on genitals, perineum, or in the rectum or mouth. They go away by themselves in 3-6 weeks, but infection doesn't.
Treatment: One intramuscular (IM) penicillin shot. For immune suppressed, three weekly penicillin shots.
Incubation/Infectiousness: Usually begins 6-12 weeks after infection, so may overlap with primary infection stage. Physical contact with rash may spread infection. Symptoms can come and go for up to a year.
Symptoms: Rash and penny-sized sores on palms, feet, or elsewhere: hair loss; sore throat; lymph node swelling, skin growths on body folds, mucus patches on mouth or genitals.
Treatment: See primary stage.
Incubation/Infectiousness: Only transmissible in early part of this stage (less than one year.)
Symptoms: Chancres or rashes may recur in early stage. After a year, detectable only with blood tests.
Treatment: Single IM penicillin shot (early latent). Three weekly IM penicillin shots (late latent)
Incubation/Infectiousness: One-third of people reach this stage, also called neurostage, also called neurosyphilis. Progressors for years and decades. Not transmissible in this stage.
Symptoms: Damage to heart, eyes, brain, nervous system, bones, joints. Can result in mental illness, blindness, heart disease and death.
Treatment: IV penicillin, every 4 hours daily for 10-14 days.
SUSSING OUT SYPHILIS
While condoms are the best prevention,
syphilis testing is a must for all HIVers. "If you're having sex,
especially without condoms, make sure to get retested regularly,"
says Ken Mayer, MD, of Fenway Community Health in Boston. There
are three ways to go:
Testing your sore (or its fluid).
Doctors with a "dark-field" microscope can see T. pallidum
in a scraping from your chancre. That is, if you know you have
a chancre, which most people don't.
Blood tests. A first test looks
for nonspecific antibodies, but anything from rheumatoid arthritis
to recent IV-drug use to HIV itself may cause a false positive.
Labs perform a different, second test -- looking for a T. pallidum-specific
antibody -- to confirm a positive result. Caveats: It takes up
to six weeks to develop enough antibodies to show a positive result
with the initial test and severely immune-compromised people may
not test positive at all. The test also doesn't distinguish between
maternal and newborn antibodies and can't reliably detect neurosyphilis.
With confirmatory tests, people infected with syphilis once will
test positive for life, even after treatment. Physicians rely
on clinical knowledge and patients' sexual history to confirm
A spinal tap. Since syphilis may
progress to neurosyphilis in a matter of months, rather than years,
in people with weak immune systems, spinal taps may be used to
check for neurological impact. "Combination HIV therapy seems
to have made rapidly progressing neurosyphilis seem less common,"
says Mayer, "but it's important to rule it out." HIV can elevate
protein and white blood cell levels in spinal fluid, markers that
can be mistaken for syphilis.