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Syphilis, the ‘Great Pretender,’ is back

The shock resurgence of an old disease is causing pain and misdiagnoses. New cases are outpacing public health officials’ ability to keep up.

An Alberta, Canada, Department of Public Health venereal disease poster from 1925.Provincial Archives of Alberta/Wikimedia Commons

Tim could not sleep; his body ached from deep within. He had a dull headache. Everything hurt. For the past few days he’d had no appetite, a low-grade fever, a sore throat, and enlarged lymph nodes, but in the morning it was the rash that caught his attention. A red, raised rash blanketed his chest and slowly crept down his arms and legs.

For weeks he was in and out of the doctor’s office and the emergency room as the rash spread. Tim lost weight and a white patch appeared in his throat, with no clear answers until there was one: syphilis.


Like a fever dream, syphilis, the “Great Pretender,” has silently, steadily, and lethally been twisting its way back into our lives. Primarily a sexually transmitted infection, it can also be spread by other bodily fluids or from an infected mother to her unborn child. It is called the Great Pretender in medical circles because of the variety of symptoms that mimic other diseases, leading to misdiagnosis and delayed treatment.

An AIDS Healthcare Foundation billboard warns of the dangers of congenital syphilis with a link for the public to get information on testing and treatment.

Syphilis can cause stillbirths, congenital defects, aneurysms, changes in personality, memory loss, and even paralysis; it is a disease that was so uncommon when I did my medical training 17 years ago that I cannot recall ever seeing a case. Now syphilis is something I have to consider much more often in my work in the emergency department.

The number of syphilis cases in the United States is now the highest it has been since 1950. Less than 25 years ago, there were only 11.2 cases of syphilis per 100,000 people. In 2021 there were 53.2 cases per 100,000. Congenital syphilis cases have grown by over 900 percent in some regions of the country. As cases climb, public health is struggling to keep up. Health care professionals are left flat-footed because they lack knowledge about the disease and have inadequate access to basic antibiotic treatment.


The fight against syphilis has had a long and complicated past, and the present approach appears to be no different. We continue to turn a blind eye to a disease slowly and silently spreading, accelerated by great inequities in our systems of health care and public health. We are left with a testable, treatable, and preventable disease that is spreading virtually unchecked.

The lack of public attention to this infection is exacerbating the problem. As is a concerning shortage of penicillin. One of our oldest antibiotics is now regularly in short supply, leaving many states to ration the little they have left. Louisiana recently reported that one of its largest federally qualified health centers, which provide health care to the poorest in their communities, had no penicillin. Meanwhile, it is commonly available in wealthy suburbs to treat strep throat. In our noncontrolled US health care experiment, we have separated public health from health care and allowed the market to determine access. Again, we see communities of color and the poor go without treatment.

To reverse these trends, we need: increased CDC funding for a national strategy to combat rising numbers of syphilis diagnoses; modifications in guidelines from key public health organizations and clinical partners; a coordinated and focused federal effort to increase the availability of treatment; increased research and a focus on low-cost point-of-care testing; and a national media campaign to raise awareness among the public.


Otherwise, T. Palladium, the small spirochete that causes syphilis, will continue to spread.

Dr. Anne Zink is president of the Association of State and Territorial Health Officials and is chief medical officer for the Alaska Department of Health.