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Year : 2016  |  Volume : 37  |  Issue : 1  |  Page : 90-91

Syphilis incognito: Resurgence of the covert devil

Department of Dermatology, Venereology and Leprosy, MGM Medical College and Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication14-Apr-2016

Correspondence Address:
Shaurya Rohatgi
502/A, Sai Prasad Residency, Sector 10, Kharghar, Navi Mumbai - 410 210, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7184.176216

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How to cite this article:
Rohatgi S, Jindal S, Viradiya HM. Syphilis incognito: Resurgence of the covert devil. Indian J Sex Transm Dis 2016;37:90-1

How to cite this URL:
Rohatgi S, Jindal S, Viradiya HM. Syphilis incognito: Resurgence of the covert devil. Indian J Sex Transm Dis [serial online] 2016 [cited 2020 Jul 11];37:90-1. Available from:


Although recent data suggest very low prevalence rates of syphilis, are we moving toward elimination, or is there a resurgence and change in the pattern of presentation? In addition, the emergence of HIV infection has increased the importance of measures aimed at the control of sexually transmitted infections (STIs) such as syphilis.

A 28-year-old female, with 12 weeks of amenorrhea (G2P1A0L1), was found to be venereal disease research laboratory (VDRL) positive during routine antenatal checkup. The pregnancy was terminated considering the risk of congenital syphilis. A detailed history and thorough clinical examination revealed no signs of syphilis. The patient refused any premarital or post/extramarital sexual contact. Repeat VDRL of the patient and her husband was positive (1:16 and 1:32, respectively). Her husband was also asymptomatic, and clinical examination was normal. He gave history of unprotected premarital sexual exposure with multiple partners 14 years back but no extramarital sexual contact. Subsequently, both cases were subjected to the treponema pallidum hemagglutination assay, which also came out to be positive. Both patients were diagnosed as cases of syphilis incognito (possibly late latent) and treated with three doses of injection benzathine penicillin G.

Syphilis incognito is a subtype of latent syphilis (early or late) which runs a subclinical course from the time of infection until its diagnosis by routine serologic screening. These patients are completely unaware of when, where, how, or by whom they had been infected, report no signs or symptoms consistent with primary or secondary syphilis, and are diagnosed as having syphilis accidentally during routine serologic screening.

A literature search revealed two retrospective, epidemiological studies reporting the patterns of STIs in India. Narayanan (1990–2000)[1] found syphilis to be the most common (57.3%) genital ulcer disease; however, a later time frame in Sasidharanpillai et al.'s study [2] (2003–2012), syphilis accounted for only 5.6% of the total STI cases. Although statistically insignificant, the latter also witnessed a rise in the number of syphilis cases during the second half of the study period. Moreover, greater than 90% belonged to the category of syphilis of unknown duration. However, the former reported only 8.3% of latent syphilis. A similar study from Puducherry [3] also found latent syphilis as the most common presentation (78.6%) among the total diagnosed cases of syphilis. Therefore, this exponential decline in the number of cases of syphilis was coupled with dominance of incognito or latent cases toward the latter half of the past 20 years.

These findings have been corroborated in other parts of the world where screening programs have found a high percentage of asymptomatic cases.[4] An increased incidence of syphilis from 2.40 to 8.19 cases/100,000, people was seen in Shandong province of China between 2004 and 2012.[5] However, latent cases did not show dominance over other forms, and the increase in incidence of all forms of syphilis was equivocal. Reports from the USA suggest that the prevalence of syphilis in heterosexuals continue to decline, and resurgence has only been seen in men who have sex with men.[6]

A rampant inadvertent use of prescription and nonprescription antibiotics is prevalent in our country. The resurgence of syphilis incognito or latent syphilis may root from partial cure of the disease due to the widespread use of penicillins and cephalosporins for common infections.[1] HIV infection and homosexual behavior are also cited as major risk factors. These patients may remain as late latent syphilis cases. Many years after infection, VDRL can become nonreactive even in untreated or inadequately treated patients. An immunodeficiency state-like HIV infection can place these inadequately treated patients at risk for reactivation.

The cases discussed in this report coupled with the recent changing epidemiological patterns of syphilis raise some concerns. In the years to come, will there be a rise in the number of tertiary syphilis cases as a consequence of rise in the proportion of latent syphilis? Has the historical “great imitator” changed into a “covert devil”? The need of the hour is a large-scale screening program to discern the prevalence in other parts of the country and curtail the risk of an epidemic.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Narayanan B. A retrospective study of the pattern of sexually transmitted diseases during a ten-year period. Indian J Dermatol Venereol Leprol 2005;71:333-7.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
Sasidharanpillai S, Bindu V, Riyaz N, Beegum Sherjeena PV, Rahima S, Chandrasekhar N. Syphilis among sexually transmitted infections clinic attendees in a tertiary care institution: A retrospective data analysis. Indian J Dermatol Venereol Leprol 2014;80:161-2.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
Devi SA, Vetrichevvel TP, Pise GA, Thappa DM. Pattern of sexually transmitted infections in a tertiary care centre at Puducherry. Indian J Dermatol 2009;54:347-9.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
Georgala S, Schulpis KH, Georgala C, Karikas GA. Syphilis screening programme in Athens, 1974-98. Sex Transm Infect 2000;76:53.  Back to cited text no. 4
Liu D, Chu T, Chen S. The syphilis epidemic in Shandong province, China: An analysis based on surveillance data from 2004 to 2011. Indian J Dermatol Venereol Leprol 2013;79:553.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
Peterman TA, Heffelfinger JD, Swint EB, Groseclose SL. The changing epidemiology of syphilis. Sex Transm Dis 2005;32 10 Suppl:S4-10.  Back to cited text no. 6


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