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Treponematosis (Endemic Syphilis) Clinical Presentation

  • Author: Steven Fine, MD, PhD; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
Updated: Sep 25, 2015


Patients with treponematosis may present with a characteristic rash or lesions that either do not heal or that continue to spread.

Patients often have a history of living in or extended travel to endemic areas.

Patients in later stages may present with various skin, bone, and joint manifestations.



Endemic syphilis (bejel) (T pallidum endemicum)

The primary lesions are painless, white, mucinous ulcers within the oral cavity, where they may be overlooked.

Secondary lesions may be in the mouth or widely disseminated. The secondary lesions may be papules, macules, or various other rashes.

The organism may infect the periosteal space, which leads to bone deformities.

Late in the disease course, a condition known as gangosa (destruction of nasopharyngeal cartilage) may occur.

Ocular manifestations include uveitis, optic atrophy, and chorioretinitis.[7]

Pinta (T carateum)

Pinta, which occurs in the Caribbean and Central and South America, is more common in young adults. It is favored by an arid rather than humid climate. Over the past 2 decades, the incidence of pinta has been reduced to only several hundred reported cases annually.

The primary lesions appear 1-3 weeks after inoculation as slowly enlarging copper-colored papules, which may become hyperkeratotic and blue. Smaller satellite lesions may be observed and may coalesce with the larger ones. The lymph draining this area may be swollen. Lesions may persist for years and may heal, leaving hypopigmentation.

Secondary lesions may develop within 3-12 months as small papules, which are often located at the site of primary lesions. The lesions may be numerous and are called pintids. They are initially red but can become pigmented and appear blue over time. Lesions may later become depigmented to varying degrees, leading to a mottled appearance. Later manifestations are limited to cutaneous involvement. The deeper tissues or viscera are not involved.

Yaws (T pallidum pertenue)

The primary lesion occurs 2 weeks to 6 months after inoculation. It begins as a papule that typically becomes a large papilloma. This may persist for several months and then may resolve spontaneously, often with scarring. During this stage, the treponeme may disseminate via the bloodstream or the lymphatics or topically through excoriation by the individual.

Secondary disease can involve multiple cutaneous lesions, including macules, papules, nodules, hyperkeratoses, and ulcerations. Lymphadenitis with swollen and tender lymph nodes may occur proximal to lesions. Periosteal infection and destruction of cartilage occur later in the course of the disease. See the image below.

Nigerian boy with ulcerative skin lesions characte Nigerian boy with ulcerative skin lesions characteristic of yaws. Courtesy of the CDC/Dr. Lyle Conrad.

The initial lesions characteristically resolve spontaneously by 6 months but then recur after a latent period. Relapses often occur for up to 5 years, after which they diminish in severity and frequency.

Approximately 10 -40% of patients with untreated yaws develop late disease, including periosteal lesions that damage bone.

Deformities are also observed, including saber shins caused by chronic periosteal infection of the tibia and gangosa, as well as destruction of the cartilage in the nose.

Other late-stage manifestations include hyperkeratoses of the palms and soles, which may fissure, predisposing to painful secondary bacterial infections, and gummas of the skull, sternum tibia, and other bones.[8]



Direct contact with lesions, or in the case of endemic syphilis, fomites, spreads treponematoses.

Endemic syphilis (bejel) (T pallidum endemicum): The organism can be indirectly transmitted onto objects and by direct contact with lesions. Much of the transmission is thought to be from mouth-to-mouth contact or from shared eating utensils or drinking cups.

Yaws is transmitted by direct exposure to skin lesions that shed the treponemes.

Contributor Information and Disclosures

Steven Fine, MD, PhD Associate Professor, Department of Internal Medicine, Division of Infectious Diseases, University of Rochester School of Medicine

Steven Fine, MD, PhD is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America, Phi Beta Kappa

Disclosure: Nothing to disclose.


Lynn S Fine, PhD, MPH Manager of Clinical Microbiology Laboratory, ACM Medical Laboratories; Adjunct Professor, Department of Biology, St John Fisher College and Nazareth College

Lynn S Fine, PhD, MPH is a member of the following medical societies: American Public Health Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John L Brusch, MD, FACP Assistant Professor of Medicine, Harvard Medical School; Consulting Staff, Department of Medicine and Infectious Disease Service, Cambridge Health Alliance

John L Brusch, MD, FACP is a member of the following medical societies: American College of Physicians, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Additional Contributors

Jeffrey M Zaks, MD Clinical Associate Professor of Medicine, Wayne State University School of Medicine; Vice President, Medical Affairs, Chief Medical Officer, Department of Internal Medicine, Providence Hospital

Jeffrey M Zaks, MD is a member of the following medical societies: American College of Cardiology, American College of Healthcare Executives, American Association for Physician Leadership, American Medical Association

Disclosure: Nothing to disclose.

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Nigerian boy with ulcerative skin lesions characteristic of yaws. Courtesy of the CDC/Dr. Lyle Conrad.
Photomicrograph (540X) of Treponema carateum obtained from an early pinta lesion. Courtesy of the CDC.
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