Chicago doctors reported in a recent study a shift in who contracts syphilis and experiences the infection’s rare and alarming symptoms. The change comes as syphilis cases continue to spike nationwide, and is prompting public health experts in the city to call for more effective and widespread screening.
The symptoms — headaches, vision and hearing problems, and even mental changes — are collectively called NOO syphilis, for neurosyphilis, ocular syphilis and otic syphilis. According to the study, which was presented last month at the 2024 Epidemic Intelligence Service Conference in Atlanta, health care providers in Chicago are now seeing syphilis cases that don’t present typical early symptoms, such as sores or rashes, and instead show signs of NOO syphilis.
Dr. Amy Nham, co-author for the study who is a CDC officer and an epidemiology fellow at the Chicago Department of Public Health, told the Chicago Sun-Times public health officials are still working out exactly why this shift has occurred, but the findings demonstrate a need for health care providers to conduct better and more widespread syphilis screening.
“We’ve been seeing an increase in syphilis nationwide,” Nham said. “There could also be an increase in untreated or inadequately treated patients, which was worsened by shifting resources during COVID. And the untreated syphilis infections could be leading to more severe manifestations.”
NOO syphilis cases are rare; researchers identified 28 such cases in Chicago reported between January and August of 2023. (According to the Chicago Department of Public Health, there were 806 primary and secondary syphilis cases in 2022.) Nineteen, or 68%, “lacked typical syphilis symptoms,” the study says.
But the findings were noteworthy for showing who is impacted. Patients ranged in age from 23 to 82 years old, and 75% were men and 71% were Black, according to the study. Black men generally are impacted by syphilis more than white men, according to data from the Centers for Disease Control and Prevention.
Only one in three patients were HIV-positive — significant because NOO syphilis is often seen among people living with HIV, the study says. And 54% of the patients studied were heterosexual men, while about 20% identified as homosexual. NOO syphilis typically impacts men who have sex with other men, or MSM, according to both the study and the CDC.
‘We need a shift in messaging’
Dr. Irina Tabidze, the director for the city health department’s Syndemic Infectious Disease Bureau, said the shift in NOO syphilis cases is a part of a broader spike in syphilis infections, most notable among heterosexual women and men. For years, there has been strong public health messaging on STIs geared toward men who have sex with other men, she said, especially explaining the benefits of the HIV preventive drug PrEP. But there has not been much of a focus on STI prevention among the heterosexual population.
“We need a shift in the messaging,” Tabidze said. “We need to develop more targeted messaging for the heterosexual population so they know that ... syphilis is not only among MSM, but the heterosexual population as well.”
“Clinicians should consider NOO syphilis even in persons presenting without typical syphilis signs and symptoms and persons without HIV,” the study recommends.
All syphilis cases in the U.S. jumped 80% from 2018 to 2022, according to the CDC, though cases increased in Illinois by 28% during that same period. Cases of congenital syphilis, where a baby is born with the disease, have also spiked in recent years.
Dr. Michael Angarone, an infectious disease specialist at Northwestern Memorial Hospital, said the Infectious Disease Center in recent years has seen manifestations of syphilis “that we typically don’t see early on” such as syphilitic eye disease or hepatitis. Those are typically associated with the second stage of the infection, he said.
Angarone added the atypical symptoms may be partly attributed to patients missing early stages of syphilis who then seek medical care when more discernible issues arise.
Syphilis infections typically develop in stages, according to the CDC. Each stage can have different signs and symptoms. It’s caused by bacteria after coming into direct contact with a syphilis sore called a chancre, which usually develops in the first stage.
“The early manifestations of syphilis sometimes can be missed, so when you have the chancre it can be painless and you might not know you have it, or it may be in an area of the body you don’t recognize that something is there,” Angarone said.
Chancres can last 3 to 6 weeks, the CDC said. A rash can develop during the second stage in addition to sores. Other symptoms of the second stage include weight loss, fever, muscle aches and hair loss.
These symptoms may go away on their own without treatment, but it doesn’t mean the infection has cleared up, the CDC said. Without treatment, syphilis can exist in the body for decades. If left untreated, it can spread to the brain and nervous system, the most serious forms of the infection. And since providers moved to telehealth appointments during the pandemic, it’s harder for doctors to spot early syphilis if they aren’t examining patients in person, Tabidze said.
Angarone said it’s important for people to get tested, even if they have no symptoms, noting that syphilis can also be asymptomatic. The infection is curable with antibiotics, but treatment might not be able to undo damage caused if it’s allowed to run rampant.
“We need to find better ways to encourage people to get tested, everyone to get tested, so that we can identify as many cases of syphilis as we can and we can treat it,” he said.
