An 83-year-old man in Belgium baffled his physicians when he arrived at the hospital with intense itching, a spreading rash, facial nerve paralysis, liver inflammation, and kidney dysfunction, only to receive a diagnosis of syphilis with no identifiable source of transmission. The case, published as a clinical problem-solving report in The New England Journal of Medicine, has drawn attention not just for its medical rarity but for what it reveals about a disease many assume belongs to a younger population. Against a backdrop of rising syphilis rates across Europe and the United States, the Belgian case exposes blind spots in how clinicians screen older adults for sexually transmitted infections.
A Diagnosis That Defied Expectations
The patient presented with pruritus, rash, facial nerve palsy, cholestatic hepatitis, and nephrotic-range proteinuria, a constellation of symptoms that initially pointed clinicians toward autoimmune or malignant causes. Syphilis was not the first suspect. The New England Journal of Medicine case report, titled “Spiraling into a Distant Past” (DOI: 10.1056/NEJMcps2507868), details how the diagnosis was ultimately confirmed through serology and biopsy. The neurologic findings, including facial nerve palsy, placed this squarely in the territory of neurosyphilis (a late-stage complication that is uncommon even among younger patients with untreated infections). The clinicians also documented liver and kidney involvement, illustrating how syphilis can masquerade as more familiar chronic diseases when it reaches advanced stages.
What made the case especially puzzling was the absence of any reported recent sexual contact or other clear route of exposure. Syphilis is caused by the spirochete bacterium Treponema pallidum and is overwhelmingly transmitted through sexual activity. In an 83-year-old patient living in Belgium with no documented risk factors, the source of infection remained a mystery. The authors noted that the man’s symptoms had evolved over months, suggesting a smoldering process that went unrecognized until multi-organ damage was evident. The case challenges a common clinical assumption: that syphilis screening is unnecessary in people in their 80s and other geriatric populations. When doctors do not think to test for it, multi-organ damage can progress unchecked, as it apparently did here, and opportunities to interrupt transmission are missed.
Syphilis Is Surging, Not Fading
The Belgian case would be easier to dismiss as an isolated curiosity if syphilis were declining. It is not. The U.S. Centers for Disease Control and Prevention reported provisional 2024 data showing continued increases in primary and secondary syphilis cases alongside congenital syphilis counts that remain at alarming levels. Across the Atlantic, the European Centre for Disease Prevention and Control published its annual epidemiological report for 2023, documenting confirmed-case counts, notification rates, and demographic breakdowns that show syphilis rates in the EU and EEA have climbed sharply in the post-pandemic period. The burden remains heavily male-skewed, but age distribution data from the ECDC report suggests the infection is not confined to any single demographic bracket, with cases documented well into older age groups, including people in their 80s.
Globally, the picture is similarly concerning. The World Health Organization’s sexually transmitted infection dashboard offers region-specific trends that show syphilis incidence rising between 2020 and 2022 in several parts of the world. These model-based estimates underscore that the upward trajectory is not a statistical artifact but a reflection of real gaps in screening, treatment access, and public awareness. WHO regional offices, including the African Region represented by the WHO AFRO portal and the Eastern Mediterranean office accessible via the EMRO site, have highlighted how limited diagnostics, stigma, and competing health priorities hamper efforts to control curable STIs. In that context, an undetected case in an 83-year-old European man is less an anomaly, and more a reminder that surveillance systems are missing infections at both ends of the age spectrum.
Why Older Adults Fall Through the Cracks
Most syphilis screening guidelines and public health campaigns focus on populations considered high-risk: men who have sex with men, pregnant women, and younger sexually active adults. Older adults rarely appear in that framework. The Belgian case exposes the cost of that omission. When an 83-year-old patient arrives with rash, liver problems, and neurologic symptoms, clinicians are far more likely to pursue workups for cancer, autoimmune hepatitis, or stroke than to order a rapid plasma reagin test. Age-related stereotypes about sexuality, coupled with a desire not to embarrass patients, can make providers reluctant to ask detailed sexual histories. The result is delayed diagnosis and, in cases involving neurosyphilis, potentially irreversible neurologic damage that might have been prevented with earlier penicillin treatment.
The mystery of the transmission source adds another layer of difficulty. While sexual transmission remains the dominant pathway, some infectious disease specialists have raised questions about whether non-sexual routes, including contact with infectious lesions or, in rare historical accounts, contaminated instruments, could play a role in elderly populations living in close-contact settings such as care facilities. No evidence from the NEJM case report confirms any specific alternative route for this patient, and the question remains open. But the fact that clinicians could not identify a source at all points to a broader surveillance gap: if public health systems are not looking for syphilis in older adults, they will not find it, and they certainly will not trace it. That blind spot complicates contact tracing and leaves unanswered whether other residents, partners, or caregivers may also be at risk.
Diagnostic Tools Are Expanding, but Gaps Persist
On the diagnostic front, regulators have taken steps to widen access to testing. The U.S. Food and Drug Administration has issued marketing authorization for a test designed to increase access to the first step of syphilis diagnosis, a move coordinated with the broader infectious disease agenda of the U.S. Department of Health and Human Services, whose priorities are outlined on the HHS website. Faster, more accessible screening could help catch cases earlier, particularly in primary care and community clinics where older patients are most likely to present with vague symptoms. These tools are especially important for detecting latent infections that might otherwise go unnoticed until complications such as neurosyphilis or cardiovascular involvement emerge.
In Europe, antimicrobial stewardship and surveillance initiatives hosted by the ECDC, including the antibiotic resistance platform, emphasize prudent use of antibiotics while maintaining timely treatment for confirmed infections like syphilis. That balance is crucial because penicillin remains highly effective against Treponema pallidum, but inappropriate or incomplete regimens could, in theory, foster resistance. Public health officials also stress the value of integrating STI testing into broader preventive services. For example, EU health authorities use the vaccination information portal to communicate about immunization schedules and infectious disease risks, a model that could be adapted to raise awareness of syphilis screening for adults beyond reproductive age. Yet even with better tests and communication channels, clinicians still need to consider syphilis in their differential diagnoses for older patients. Otherwise, the tests will never be ordered.
Rethinking Risk, Screening, and Stigma
The Belgian case underscores the need to rethink how risk is defined in clinical and public health practice. Chronological age alone is a poor proxy for sexual activity or vulnerability to infection. Many older adults remain sexually active, may have new partners after divorce or widowhood, and may be less likely to use condoms than younger people who grew up with HIV prevention campaigns. When clinicians assume that someone in their eighties is not at risk for syphilis, they import their own biases into medical decision-making. Updating guidelines to recommend routine STI risk assessment for adults of all ages (rather than capping attention at 64 or 74) could help normalize these conversations and reduce missed diagnoses.
Stigma is another powerful barrier. Older patients may feel embarrassed to disclose sexual histories, particularly in cultures where sexuality in later life is rarely acknowledged. Providers may share that discomfort, skipping questions that could feel intrusive. In that silence, infections like syphilis can flourish undetected. Public health messaging that explicitly includes seniors, alongside younger adults, pregnant people, and key populations, could help dismantle the myth that STIs are only a young person’s problem. The NEJM report on the 83-year-old Belgian man demonstrates that when clinicians finally did test for syphilis, they found an explanation for a bewildering array of symptoms. The broader lesson is that asking the right questions and ordering a simple blood test can prevent months of suffering, avoid costly diagnostic odysseys, and, in some cases, save lives.
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*This article was researched with the help of AI, with human editors creating the final content.
