Int J STD AIDS OnlineFirst, published on December 17, 2015 as doi:10.

1177/0956462415622772

Original research article

International Journal of STD & AIDS
0(0) 14
! The Author(s) 2015
Clinical diagnosis of syphilis: a ten-year Reprints and permissions:
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retrospective analysis in a South DOI: 10.1177/0956462415622772
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Australian urban sexual health clinic

CE Forrest1 and A Ward2

Abstract
National notifications for infectious syphilis in Australia have increased in recent years. Outside of sexual health clinics,
junior clinicians seldom encounter this disease in its infectious stage (primary, secondary and early latent). With such a
variable clinical presentation, textbook teaching is no substitute for real-life experience. The importance of accurate
classification and staging of disease is relevant to the risk of transmission and determines treatment duration. In this
article, the authors review the clinical presentation of syphilis over ten years in an urban sexual health clinic with a focus
on the clinical presentation and diagnosis of infectious syphilis, in particular secondary syphilis, compared with that
outlined in the Australian National Notifiable Diseases Surveillance System guidelines. This retrospective review of all
patients diagnosed with syphilis at an urban sexual health clinic showed that between 2005 and 2015, 226 cases of syphilis
were diagnosed. Documentation of impression of clinical staging of disease was present in 46% of the cases. Seventeen of
these cases were recorded as secondary syphilis. The criteria used by clinicians to diagnose the secondary syphilis cases
were consistent with criteria defined by the Australian National Notifiable Diseases Surveillance System. All cases of
secondary syphilis had at least one cutaneous manifestation of disease. The demographic of the cohort of syphilis cases
was consistent with that recorded in the literature. This review showed that the clinicians diagnosis of secondary syphilis
in this service is consistent with the National Notifiable Diseases Surveillance System guidelines. Continuing education of
junior medical staff is important to facilitate diagnosis and improve documentation of clinical staging, minimise disease
transmission and ensure appropriate treatment.

Keywords
Syphilis, Australia, diagnosis

Date received: 22 July 2015; accepted: 23 November 2015

Introduction of reactive serology to public health authorities. In

Syphilis is a sexually transmitted infection (STI) caused
by the spirochete bacterium Treponema pallidum. It is
characterised by a multistage course of disease, in
which symptomatic and asymptomatic phases occur.1
While cutaneous lesions are the hallmark, the clinical
manifestations are manifold and highly variable in
appearance.2
Clinical characteristics of syphilis have been
described for centuries, but since the advent of penicil-
lin, this disease has become uncommon. Outside of
work in sexual health clinics and remote indigenous
communities, junior clinicians today rarely encounter
cases of infectious syphilis.
Syphilis is a notiable disease under the public
health acts of all Australian states and territories.3
Pathology laboratories must mandatorily report cases
some jurisdictions, the healthcare professional whom
diagnoses a case is also required to notify the jurisdic-
tional public health authorities.3 Data from notica-
tions are stored on national databases and used to
assist contact tracing, monitoring of disease outbreaks
and treatment administered.3
1
Dermatology registrar, Royal Adelaide Hospital, Adelaide, South
Australia, Australia
2
Consultant Sexual Health Physician, Clinic 275 STD Services, Royal
Adelaide Hospital, Adelaide, South Australia, Australia
Corresponding author:
Charlotte Forrest, Dermatology Registrar, Royal Adelaide Hospital,
North Terrace, Adelaide, South Australia, 5000, Australia.
Email: charlotteforrest1@gmail.com

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2 International Journal of STD & AIDS 0(0)
Since the advent of penicillin and subsequent reduc-
tion in the burden of disease, there has been a gradual
rise in incidence.4 In Australia, syphilis predominantly
aects men who have sex with men (MSM) and indi-
genous people in remote locations.5 National notica-
tions for infectious syphilis more than doubled from 3.0
to 6.7 cases per 100,000 population between 2004 and
2007 after which they declined slightly before returning
to 6.7 in 2012. In 2012, infectious syphilis notication
rates in men was eight times that of women.3,6 In 2012,
the notications of infectious syphilis in Aboriginal and
Torres Strait Islander people occurred at ve times the
rate of non-indigenous people. Outbreaks continue to
occur in remote indigenous communities.6
To our knowledge, there are no existing syphilis
audits from an Australian population group focused
on the clinical presentations of patients diagnosed
with early syphilis, nor are there existing audits on
the implementation of the National Notiable diseases
case denition guidelines in clinical practice. The
importance of correct classication is related to
the risk of transmission and treatment duration.
Misclassication can have a negative impact on appro-
priate treatment duration and contact tracing.7
We reviewed ten years of data in an urban sexual
health clinic, with a particular emphasis on clinical
presentation of infectious syphilis and diagnosis and
staging of disease. This was compared and contrasted
with the Australian National Notiable Diseases
Surveillance System (NNDSS) case denition guide-
lines (Appendix 1).
Aim
The aim of the study is to review the clinical presenta-
tions of syphilis and quantify the clinical signs of
secondary syphilis among syphilis cases attending an
urban sexual health clinic. Secondarily, to evaluate
the clinical diagnosis of secondary syphilis in this
clinic compared with published case denition guide-
lines from the Australian NNDSS, and whether the
case denition is appropriately implemented for disease
notication and surveillance.
Methods
Patient data were collected retrospectively using the
database at Clinic 275, the STI clinic of the Royal
Adelaide Hospital. The standardised case-note pro-
forma was used to verify the diagnosis and pathology
results and obtain relevant data. Data collected
included year of diagnosis, age, gender, reason for pres-
entation, examination ndings, pathology results, sta-
ging of disease, treatment received, HIV status and, for
male patients, gender of sexual partners. Cases were
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excluded if the computer-coded diagnosis did not
match the diagnosis recorded in the case notes. All
data were manually collated and analysed in
de-identied disaggregated form. Patient names were
protected with use of unit record numbers and a
further de-identication coding system. As this study
was conducted for quality assurance purposes, the
Royal Adelaide Hospital Human Research Ethics
Committee indicated that ethics approval was not
required.
Case denition criteria from the NNDSS were com-
pared with criteria used by doctors in the clinic when
making a diagnosis. The NNDSS criteria for the
category of syphilis of less than two years duration
are listed in Appendix 1. This category encompasses
primary, secondary and early latent. In this audit, we
focus on secondary syphilis. The reason for this is our
interest in dermatological manifestations of disease and
that the secondary syphilis cohort diagnostic data were
most clearly documented. Clinical signs of secondary
syphilis infection include generalised non-tender lymph-
adenopathy, rash (macular, papular, papulosquamous
and pustular) aecting the trunk or palmoplantar
areas, supercial mucosal erosions, condylomata lata,
alopecia and evidence of a healing chancre.4
Constitutional symptoms and involvement of other
organ systems were omitted due to inconsistencies
and low rate of documentation.
Results
The database search identied 277 cases of newly diag-
nosed syphilis between 2004 and 2014. After review of
the medical records, 51 cases were excluded due to
coding error or identication of a duplicated entry,
leaving a total of 226 cases.
Ninety percent of cases (204/226) were men, 71%
(145/204) of whom were MSM. Sixteen percent
(37/226) were HIV positive, 34 of whom were men
and 20/34 (59%) were identied as MSM.
Staging of the disease was documented by the treat-
ing clinician in only 46% of cases (104/226), with no
documented evidence of an attempt to stage disease in
the remaining 122 cases. Sixteen percent of staged cases
(17/104) stated a diagnosis of secondary syphilis. The
other staged cases were documented as primary (43%),
early latent (7%) and late latent (34%).
The criteria used to diagnose the 17 cases of second-
ary syphilis was compared and contrasted with that
outlined in the NNDSS case denitions (Appendix 1).
Two cases did not have complete data because the
patient refused physical examination by the clinic
doctor. The remaining 15 cases of secondary syphilis
were diagnosed using criteria consistent with that of
the NNDSS (Appendix 1). The NNDSS criteria
Forrest and Ward 3

fullled were laboratory suggestive evidence and clinical
evidence in 80% (12/15) of cases; denitive laboratory
evidence was used to diagnose the remaining 20%
(3/15) of cases.
The physical examination ndings of the secondary
syphilis cases were reviewed (Table 1). The examination
ndings categorised as cutaneous manifestations com-
prised: a healing chancre; macular, papular, papulos-
quamous or pustular rash; condylomata lata; alopecia
and mucosal erosions. The presence of lymphadenop-
athy was also noted. Of the 15 patients with physical
examination data, all had at least one documented
cutaneous manifestation. A maculopapular rash was
documented in 73% of cases (11/15). Erythematous
macules involving the palmar and plantar surfaces
were documented in 6/15 (40%) cases (2/15 palmar
only, 2/15 plantar only, 2/15 palmoplantar). Oral
supercial mucosal erosions were present in one fth
(3/15) of cases. Condylomata lata were identied in
2/15 cases. Lymphadenopathy was reported in 7/15
cases: most commonly aecting the inguinal (5/15),
followed by the cervical lymph nodes (2/15). The heal-
ing primary chancre was still visible in one third of
cases.
Sixteen percent of cases (37/226) were HIV-positive,
three of whom were women. Staging was documented
in all HIV-positive patients. Of the HIV-positive
patients, the majority had infectious syphilis, with
16/37 (43%) primary syphilis, 4/37 (11%) secondary
syphilis, and the remainder considered early and late
latent infection. There were no dermatological ndings
specic to this cohort. An oral chancre was noted in
one case of primary syphilis with HIV infection. No
cases of oral chancre were noted in the HIV-negative
group. Two of the four HIV-positive cases with second-
ary syphilis had maculopapular rash of trunk and
palmoplantar regions in addition to cervical lymph-
adenopathy. Supercial mucosal erosions were seen in
the oral cavity in both other cases. Concurrent STIs
including gonorrhoea (three cases) and genital warts

Table 1. Clinical examination findings of secondary syphilis cases.

Maculopapular
rash Superficial
distributed Palmar Plantar Palmoplantar mucosal Conylomata Healing Alopecia
Case Lymphadenopathy on trunk rash rash rash erosion lata chancre areata

1 3 Bilateral 3 3
Inguinal
2 3
3 3 3 3
4a
5 3 Cervical 3 3
6 3
7a
8 3 3
9 3 3 3
10 3
11 3 3 3
12 3 Cervical and 3 3
bilateral inguinal
13 3 Unilateral 3 3
inguinal
14 3
15 3 Unilateral 3 3
inguinal
16 3 3
17 3 3
Proportion 7/17 11/17 2/17 2/17 2/17 3/17 2/17 5/17 0/17
with feature
a
No data.

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4 International Journal of STD & AIDS 0(0)
(two cases) were diagnosed in 5/37 (14%) of patients
and candidiasis in 2/37 patients. Eleven percent (21/189)
of the HIV-negative group had concurrent STIs.
Discussion
As South Australias largest sexual health centre, the
majority of the states syphilis case notications origin-
ate from Clinic 275.8 Review of the last ten years of
syphilis diagnosed at this centre has brought to atten-
tion some matters of interest. Half of the cases had
documented staging of disease. This is inadequate.
The group of HIV-positive cases was an exception,
with staging of syphilis documented in all cases. The
importance of correct classication is related to the
risk of transmission and treatment duration.
Misclassication can have a negative impact on appro-
priate treatment duration and contact tracing.7 When
staging was attempted, there was 100% compliance
with NNDSS diagnostic criteria.
Infectious syphilis is associated with an increased
risk for HIV acquisition and transmission.5 In this
study, slightly more than half of the HIV-positive
patients had infectious syphilis. The course of disease
may be altered in HIV-positive patients and these
patients may experience atypical presentations, compli-
cating their diagnosis.2 An interesting nding in this
study was that 59% of HIV-positive men with syphilis
identied as MSM compared with 71% of HIV-nega-
tive men with syphilis. This highlights a group of MSM
who may not be comfortable identifying their sexual
orientation and may be at higher risk of acquiring
both HIV and syphilis infection.
Very few oral chancres were reported in the HIV-
positive cohort. A possible explanation for this is
higher rates of unprotected anal sex compared with
oral sex in addition to the fact that oral chancres are
easily missed.
A limitation of this audit was that statistical analysis
was not performed. Further to this data collection
relied on accurate documentation in case notes. In
some instances, this documentation was incomplete.
Conclusion
The diagnostic criteria for syphilis correlated with that
dened by the NNDSS. The number of cases of second-
ary syphilis recorded is likely to under-represent the
actual number of cases. Staging of disease appears to
be under-attempted by the treating clinician or not ade-
quately recorded.
All of the cases diagnosed as secondary syphilis
had at least one cutaneous manifestation of disease
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(see Table 1). The majority of syphilis cases were men
(90%) and MSM (71%), which is in keeping with the
current data trends available in Australia.3,6
Acknowledgements
The authors would like to acknowledge Dr Russell Waddell
for his generous time contribution and assistance in dening
the aims of this audit. Research ethics: Quality assurance
activity so exempt from requiring ethics approval from
Royal Adelaide Human Research Ethics Board.
Declaration of Conflicting Interests
The author(s) declared no potential conicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no nancial support for the research,
authorship, and/or publication of this article.
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