Trends of syphilis before, during, and after the COVID-19 pandemic in central India: A retrospective study

Abstract

Background:

Syphilis is a sexually transmitted disease that varies in presentation according to the stage of the disease. Susceptibility to penicillin contributed to the near elimination of the disease during the 1990s to 2000 period. Recently, there have been reports of the re-emergence of syphilis from all parts of the world.

Aim:

To study the clinical presentation and trends of syphilis.

Materials and Methods:

A retrospective study was conducted from January 2013 to December 2024. All clinically and/or serologically diagnosed cases of syphilis were included in the study. Medical records of all the patients attending the sexually transmitted infection clinic were analyzed concerning age, sex, clinical presentation, and laboratory investigations. Statistical analysis was done using mean, median, and proportion.

Results:

A total of 260 cases with syphilis were enrolled. The male-to-female ratio was 5.53:1. The most common stage of presentation was latent syphilis (45.6%). The most common age group affected was 21–30 years. Out of the total cases, 2.7% of cases were pregnant females, 14.18% were human immunodeficiency virus (HIV) positive, and 95 cases were men who have sex with men cases. Only two cases of congenital syphilis were detected.

Conclusion:

A resurgence of syphilis cases has been observed in the last 3 years, with latent syphilis contributing to the majority of cases. Possible factors attributed to this surge include promiscuous sexual behavior, HIV coinfection, male having sex with male, and early adolescent sexual exposure. The sudden rise in latent syphilis cases is a warning sign of resurgence in India, as it signifies the persistence of syphilis in the subclinical phase in the community.

Introduction

Syphilis is a great mimicker and has a myriad of dermatological manifestations. The exact seroprevalence of syphilis is not known or varies in various studies because of various reasons, such as social stigma, poor attendance at sexually transmitted infection (STI) clinics, and asymptomatic cases. Syphilis remains a global health problem with recent reports of resurgence from various parts of the world, including India.[1,2,3,4,5,6,7] Our study aims to understand the trends of syphilis at our institute in central India over 12 years.

Materials and Methods

It was a retrospective study conducted for 12 years, from January 2013 to December 2024. Ethical committee clearance was obtained (3676/EC/Pharmac/GMC/NGP). Medical records of all patients visiting the STI (Suraksha) Clinic at our institute were evaluated. All clinically and/or serologically confirmed cases of syphilis were included, and patients with biologically false-positive reactions were excluded. Medical records of all patients were evaluated concerning age, sex, occupation, address, marital status, detailed sexual history and practices, personal contact, whether an active or passive partner in case of men who have sex with men (MSM), use of condoms/other barrier methods, duration of symptoms, clinical presentations of syphilis, and associated other STIs. All cases were classified and treated as per CDC guidelines. All asymptomatic cases (without clinical signs and symptoms of syphilis with nonreactive/low titers VDRL and TPHA positivity) those not received prior treatment for syphilis, were considered as latent syphilis. All cases were followed up after treatment with serological investigations. Clinical photographs of patients were retrieved. Statistical analysis was done using mean, median, and proportion.

Results

The study comprised 11,045 patients with STIs, out of which confirmed syphilis was reported in 296 (2.67%) cases. Out of a total of 296 cases, 161 patients were asymptomatic (54.39%). There was a male preponderance (83.8%) in our study, and two transgender patients with secondary syphilis were also reported [Table 1]. Most of the patients were from urban areas (n = 224; 75.7%). Most males were graduates and professionals (n = 201; 68%), while students comprised 9.8% of all cases. Out of all female patients, 62.22% were housewives. Out of all cases, 57.43% of cases were married. The most commonly affected age group was 21–30 years (n = 175; 59.12%), followed by 31–40 years (n = 68; 22.97%), as depicted in Table 1. The mean age of presentation was 29.95 ± 9.19 years (range 0–83 years and median age = 25.5 years). Two cases of congenital syphilis with systemic involvement were reported in newborn males. There were rising trends in syphilis from the year 2013 (n = 5) to the year 2024 (n = 77). Before the COVID-19 pandemic, 25.42% of cases were reported, while a huge number of cases, i.e., 60.81% of cases (n = 180), were detected during the last 3 years after the COVID-19 pandemic [Chart 1]. The most common stage of the presentation was latent syphilis (n = 135; 45.6%). In the first half of the study, secondary syphilis cases were significantly higher in number, while in the second half of the study, latent syphilis cases were higher in number in the last 3 years [Table 2 and Chart 2]. All cases of primary syphilis were reported exclusively in males (n = 29). Secondary syphilis (66.67%) was the most common presentation in females, while latent syphilis was most commonly observed in males [Chart 3]. A history of unsafe sex practices was elicited in 96.8% of cases. 76% of patients had multiple sex partners. Among all cases, coinfection with human immunodeficiency virus (HIV) and commercial sex worker contacts were detected in 14.18% and 15.20%, respectively. 2.7% were pregnant females, and 95 cases were MSM [Table 3a and b]. 14.18% of total cases were detected with latent syphilis during the blood donation survey. 20.27% of cases were reported as positive during partner tracing. There were 5 cases of primary syphilis that had coinfection with HIV. There was one case of lepromatous Hansen’s disease with secondary syphilis in our study (VDRL titer 1:16). The titers of VDRL ranged between 1:2 and 1:512. The mean VDRL titers for primary syphilis, secondary syphilis, and latent syphilis were 1:16, 1:64, and 1:4, respectively. TPHA was positive in all cases of secondary and latent cases, while 90% of cases of primary syphilis had positive TPHA. Inguinal lymphadenopathy was present in 22 cases of primary syphilis [Figure 1a and b]. Psoriasiform palmoplantar plaques with collarette scales (n = 90, 70%) were the most common presentation in secondary syphilis. A genital wart was also seen in one of the secondary syphilis cases with palmoplantar involvement [Figure 1c and d]. Palmoplantar involvement was reported in the form of asymptomatic annular plaques with collarette scales [Figure 2a], diffuse erythematous scaly rash [Figure 2b], and hyperpigmented macules [Figure 2c and d]. Cutaneous rash (coppery red asymptomatic macular, papular, maculopapular, and lichenoid rash) was observed in 16 cases [Figure 3a–d]. 28 patients had generalized lymphadenopathy, while moth-eaten alopecia was seen in only 4 cases. [Figure 4a], Oral involvement and condyloma lata were reported in 6 and 12 cases, respectively [Figure 4b–d]. All patients were regularly followed up, and serological investigations were performed [Figures 5a–f, 6a–d, and 7a–e].

Table 1.

Age–sex-wise distribution of all cases

Year	0–10		11–20		21–30			31–40		41–50		51–60		>60 years		Total
	Male	Female	Male	Female	Male	Female	Transgender	Male	Female	Male	Female	Male	Female	Male	Female	Male	Female	Transgender	n (%)
2013	0	0	0	0	2	0	0	1	1	0	0	1	0	0	0	4	1	0	5 (1.69)
2014	0	0	0	0	2	2	0	1	1	0	0	1	0	0	0	4	3	0	7 (2.36)
2015	0	0	0	0	1	0	0	1	1	1	0	0	0	0	0	3	1	0	4 (1.35)
2016	0	0	0	0	2	2	0	1	0	1	0	0	0	0	0	4	2	0	6 (2.02)
2017	0	0	1	0	1	1	0	2	1	2	1	1	0	0	0	7	3	0	10 (3.38)
2018	1	0	0	0	6	3	0	5	0	2	1	1	0	0	0	15	4	0	19 (6.42)
2019	0	0	1	0	12	4	0	3	1	2	0	1	0	0	0	19	5	0	24 (8.11)
2020	0	0	1	0	15	2	0	5	1	2	0	1	0	0	0	24	3	0	27 (9.12)
2021	0	0	1	0	11	0	0	2	0	0	0	0	0	0	0	14	0	0	14 (4.73)
2022	0	0	1	0	21	1	0	6	1	3	0	0	0	0	0	31	2	0	33 (11.15)
2023	0	0	7	0	30	8	2	14	3	4	0	0	0	2	0	57	11	2	70 (23.65)
2024	1	0	3	2	41	6	0	15	2	4	1	1	0	1	0	66	11	0	77 (26.01)
Subtotal	2	0	15	2	144	29	2	56	12	21	3	7	0	3	0	248	46	2	296
Total, n (%)	2 (0.67)		17 (5.74)		175 (59.12)			68 (22.97)		24 (8.1)		7 (2.36)		3 (1.01)		83.8	15.6	0.6	296

Chart 1.

Total number of cases with respect to the COVID-19 pandemic

Table 2.

Yearwise distribution of all cases

Year	Primary, n (%)	Secondary, n (%)	Latent/unknown, n (%)	Congenital, n (%)	Total
2013	2 (6.89)	2 (1.53)	1 (0.74)	0	5
2014	2 (6.89)	1 (0.76)	4 (2.96)	0	7
2015	-	2 (1.53)	2 (1.48)	0	4
2016	1 (3.44)	3 (2.30)	2 (1.48)	0	6
2017	5 (17.24)	5 (3.84)	0	0	10
2018	1 (3.44)	11 (8.46)	6 (4.44)	1 (50)	19
2019	4 (13.79)	12 (9.23)	8 (5.92)	0	24
2020	3 (10.34)	17 (13.07)	7 (5.18)	0	27
2021	2 (6.89)	6 (4.61)	6 (4.44)	0	14
2022	4 (13.79)	12 (9.23)	17 (12.59)	0	33
2023	1 (3.44)	30 (23.07)	39 (28.89)	0	70
2024	4 (13.79)	29 (22.30)	43 (31.85)	1 (50)	77
Total	29 (9.8)	130 (43.92)	135 (45.6)	2 (0.67)	296

Chart 2.

Distribution of cases as per stage of presentation

Chart 3.

Distribution of cases as per sex and stage of presentation

Table 3a.

High-risk group associated with syphilis

Year	MSM, n (%)	HIV, n (%)	CSW contacts, n (%)	ANC, n (%)
2013	0	1 (2.38)	2 (4.44)	0
2014	0	1 (2.38)	0	0
2015	0	0	0	0
2016	1 (1.05)	1 (2.38)	0	1 (12.5)
2017	0	3 (7.14)	0	0
2018	2 (2.10)	2 (4.76)	1 (2.22)	1 (12.5)
2019	8 (8.42)	1 (2.38)	6 (13.33)	2 (25)
2020	9 (9.47)	3 (7.14)	7 (15.56)	1 (12.5)
2021	8 (8.42)	1 (2.38)	1 (2.22)	0
2022	12 (12.63)	4 (9.52)	1 (2.22)	1 (12.5)
2023	25 (26.31)	11 (26.19)	8 (17.78)	0
2024	30 (31.57)	14 (33.33)	19 (42.22)	2 (25)
Total (n=296)	95 (32.09)	42 (14.18)	45 (15.20)	8 (2.7)

HIV=Human immunodeficiency virus; CSW=Commercial sex worker; ANC=Antenatal care; MSM=Men who have sex with men

Table 3b.

Distribution of venereal disease research laboratory positivity among groups

VDRL titers	MSM, n (%)	HIV, n (%)	CSW, n (%)	ANC, n (%)	Blood bank, n (%)
Nonreactive VDRL and TPHA positive	44 (46.32)	14 (33.33)	21 (46.67)	0	42 (100)
1:8	5	1	3	0	0
1:16	8	9	4	2	0
1:32	14	6	8	1	0
1:64	11	3	4	4	0
1:128	11	6	3	1	0
1:256	1	2	2	0	0
1:512	1	1	0	0	0
Subtotal	51 (53.68)	28 (66.67)	24 (53.33)	8 (100)	0
Total	95	42	45	8	42

VDRL=Venereal disease research laboratory; HIV=Human immunodeficiency virus; CSW=Commercial sex worker; ANC=Antenatal care; MSM=Men who have sex with men; TPHA=Treponema pallidum hemagglutination

Figure 1.

Primary chancre (a and b), palmoplantar annulare plaque with collarette scales with genital wart (c and d)

Figure 2.

Secondary syphilis–annulare plaque with collarette scales (a), diffuse erythematous scaly rash (b), hyperpigmented macules (c and d)

Figure 3.

Macular syphilitic rash over trunk (a), extremities (b), palm (c), and genital (d)

Figure 4.

Moth-eaten alopecia (a), oral ulcers (b), pre- and posttreatment images of condyloma lata (c and d)

Figure 5.

(a-f) Pretreatment and posttreatment images of palmoplantar syphilis

Figure 6.

EM-like lesions in secondary syphilis in male over the back (a), upper chest (b), extremities (c), and palms (d)

Figure 7.

Posttreatment images of EM-like rash in secondary syphilis over the upper chest (a), back (b), extremities (c), palms (d and e)

Discussion

A rising syphilis trend has been observed in our study, similar to Indian studies,[1,2,3,4,5,6,7] while Gupta et al. and Baskaran et al. have observed an increased number of cases from 2017 onward to reach a significant increase in 2022, similar to our study.[8,9] After the COVID-19 pandemic, most of our cases (60.81%) were reported in our study, similar to Gupta et al.[8] and Bhaskar et al.[9] This significant rise in syphilis cases after the COVID-19 pandemic can be attributed to underreporting, reduced STI screening, unsafe sexual practices, lifestyle changes, and restrictive lockdown. An increased health-seeking behavior and healthcare accessibility post-COVID-19 pandemic could have also contributed to the increase.

Our study reported male preponderance (M: F = 5.51:1), similar to most of the previously published studies.[1,2,3,4,5,6,7,8,9] Male predominance in syphilis cases can be explained on the basis of high-risk and unprotected sexual practices, the migratory nature of job, and the higher number of HIV and MSM patients. Females are less commonly reported may be due to the asymptomatic nature of the disease and the social stigma associated with STIs. However, females are commonly detected as part of contact tracing and partner management and during antenatal checkup.

Young adults (21–30 years) constituted the major proportion (59.12%) of our cases, similar to studies conducted by Gupta et al., Baskaran et al., and Shah et al.[8,9,10] Early onset of sexual exposure among adolescents could be attributed as one of the potential reasons for the increasing number of infectious syphilis. In our study, 68% of patients were graduates and professionals, similar to Jeevanandham et al. (80%),[7] Gupta et al. (45.1%),[8] and Baskaran et al. (72%).[9] The reason for this is the increased health-seeking behavior of the literate population.

In our study, a significant number of MSM (32.09%) were reported, comparable to other studies such as Sasidharanpillai et al.,[3] Baskaran et al.,[9] Shah et al.,[10] and Wahab et al.[11] MSM is a bridge population in spreading HIV and other STIs. Promiscuous sexual behavior in the MSM group and increased reach with the boom of social media and dating applications are the factors associated with an increased number of cases in these groups.[12,13,14]

14.1% of all our cases were detected from blood donation camps, similar to studies conducted by Pinchera et al. (13.4%)[15] and Gupta et al. (16.1%).[8]

Syphilis and HIV coinfection was observed in 14.18% of our patients. The frequency of HIV–syphilis coinfection reported by Nishal et al.,[2] Jeevanandham et al.,[7] and Gupta et al.[8] was 8.8%, 13.9%, and 12.9%, respectively. The reasons behind the higher HIV infection rate among syphilis patients include high-risk behavior, mucosal breach, the asymptomatic nature of the disease, and mucosal inflammation.

In secondary syphilis, 70% had palmoplantar involvement in our study. Gupta et al. and Sivayadevi and Anandan reported that palms and soles were involved in 46.1% and 52.6% of patients.[4,8] This highlights the importance of examining palms and soles in every case of STD. In our cases, oral involvement and condyloma lata were reported in 6 and 12 cases, respectively. Oral ulcers and condyloma lata affecting the natal cleft were seen in five cases each in a study conducted by Baskaran et al.[9]

Latent syphilis is the most common stage of presentation in our study, similar to most of the studies published from India.[2,6,7,9,11] However, Gupta et al. reported secondary and latent syphilis as the most common stage and presentation,[8] and in a study by Shah et al., secondary syphilis was the most common presentation.[10] The recent rise in latent syphilis can be attributed to asymptomatic groups, improper or incomplete treatment of primary and secondary stages in non-STD clinics, increased serological screening before surgical intervention, antenatal checkups, blood donation camps, and, most importantly, the increased frequency of MSM and HIV coinfection.

Conclusion

An era of resurgence of syphilis is being observed in different parts of India. Early diagnosis, treatment, and contact tracing are essential for effective control of syphilis. Targeted screening and interventions, more vigilantly in blood banks and MSM groups, timely interview and tracking of partners, health education of high-risk individuals, and promotion of safe sexual practices are required to halt the transmission of this disease.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.