The Return of Syphilis

By R. Susan Daily, M.D., and Eunice Y. Yuen M.D., Ph.D., and the Child Committee at the Group for the Advancement of Psychiatry

The impetus for this post came from its first author, Susan Daily, M.D., who watched a 16-year-old girl die from tertiary syphilis that had previously been misdiagnosed as bipolar disorder.

As of 2024, the number of syphilis cases in the United States is increasing at an alarming rate. From 2018 to 2022, the Centers for Disease Control (CDC) reports that occurrences of syphilis in the U.S. rose 80 percent, primarily in young women. In some locales, the increase has been over 600 percent.

This describes the rising concerns.

Fourteen-year-old Marie* presented to an outpatient pediatrics clinic complaining of anxiety, especially at school where she found the noise overwhelming. Her grades fell from As and Bs to Cs during her 8^th grade year.

Marie was irritable, had headaches, irregular sleep, and started having mood swings. She has no history of seizures, head trauma, or other physical, sexual, or emotional trauma. Her primary care pediatrician (PCP) found she had a normal physical exam. Her standard bloodwork showed nothing out of the ordinary. She had no history of rash, lesions, or tick-borne illnesses. She takes no regular medications, but uses melatonin as needed for sleep and an antihistamine as needed for allergies. Marie has no known family history of mental illness.

Psychological testing revealed a significant drop in her Full-Scale Intelligence Quotient (FSIQ) from four years prior when she was evaluated for placement in a “gifted and talented” program. She now struggles with her memory and even with reality testing.

A panel of laboratory tests for sexually transmitted infections revealed a positive rapid plasma reagin (RPR) test that screens for syphilis. The panel was ordered due to knowledge of the STI rate in the local area and an effort to find a cause for the patient’s loss of IQ points. A spinal tap and cerebrospinal fluid testing resulted in a positive treponema test, confirming the diagnosis of syphilis. Marie later disclosed that she had engaged in oral sex with both a boy and a girl peer.

Marie was diagnosed with early neurosyphilis, and treated with antibiotics. She also began rehabilitation for cognitive decline and anxiety, including occupational therapy, individual therapy, family support therapy, and an individualized educational plan (IEP) at school. She received a mood stabilizer medication from an outpatient psychiatric clinic as well as anti-anxiety and sleep medications. Marie tolerated medication well and gradually improved her level of functioning to pre-syphilitic levels.

Physicians are trained to be aware of the psychiatric effects of STIs, as these are both preventable and treatable. For several centuries, the great demon was syphilis (caused by treponema pallidum infection) and later joined by Human Immunodeficiency Virus (HIV). Now frequent coinfections occur with a variety of STIs.

Classic markers of syphilis infection for each stage of infection were drilled into medical students’ brains. Of particular interest was neurosyphilis, which presents with a variety of neuropsychiatric symptoms including:

• mood disturbances
• trouble focusing
• poor memory
• headaches
• personality change
• dementia

Roles for Pediatric Mental Health Practitioners

• Testing. If clinically indicated, an STI panel should be part of a normal workup. The panel includes HIV, herpes simplex virus (HSV) type 1 and 2, chlamydia, gonorrhea, syphilis, hepatitis B and C, and human papillomavirus (HPV).
• Take a thorough sexual history. For example, physicians should inquire if a child or adolescent is engaged in sexual activity. Are there sexual encounters with boys, girls, or both? How old are their sexual partners? What kind of sex are they having? Do they practice vaginal, oral, and or anal sex? Are they using condoms or other birth control methods?
• Arrange for a physical exam. Any child, adolescent (or adult for that matter) presenting with a mental health symptom for the first time should have a thorough physical exam. The child should see their pediatrician for a full exam followed by appointments with other specialists depending on the results of the physical exam and lab tests.
• Provide information. Mental health practitioners should be prepared to discuss sexual matters and provide sexual education to their patients, even those who have not yet reached puberty. Education should prioritize safety and help-seeking.
• Mandated reporting to officials. If a practitioner suspects that an underage individual (below 18 years old) is engaging in sexual activity with older individuals or engaging in risky online sexual behaviors, they are likely mandated to report this to child welfare authorities according to the laws of their state or jurisdiction.
• Speak with families. Inform legal guardians of test results according to state or jurisdiction laws. Child welfare authorities’ involvement may be helpful, depending on the family circumstances.
• Stay updated. Stay informed through the CDC on recent outbreaks of syphilis and other STIs.

Syphilis is a treatable illness if it is recognized and treated early. Untreated, syphilis can be a “forever” disease with severe morbidity and mortality. To avoid tragic outcomes, all physicians, including psychiatrists, should be vigilant and keep the possibility of syphilis in mind when evaluating their patients.

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*Name and details altered.

R. Susan Daily, M.D., is a child psychiatrist for the Cherokee Nation in Oklahoma and volunteers her time to the local medical training programs.

Eunice Y. Yuen M.D., Ph.D., ​​​​​is an Assistant Professor of Psychiatry at Yale School of Medicine and Child Study Center and co-chair of the GAP Child Committee.