Bejel

Bejel (endemic syphilis) is a non-venereal treponemal infection caused by Treponema pallidum subspecies endemicum, mainly affecting children in arid regions.

• Endemic in the Sahel (Niger, Mali, Burkina Faso), the Arabian Peninsula, the Middle East, and parts of Australia (Aboriginal communities); cases reported in Europe and Japan.
• Transmitted by oral contact, shared drinking vessels, and skin contact in conditions of poor hygiene and overcrowding.
• Primary lesions often unnoticed in the mouth.

• Primary: small oral mucosal papule or ulcer, or nipple lesion in breastfeeding mothers (rarely seen).
• Secondary: mucous patches, split papules at the angles of the mouth, condylomata lata, generalised lymphadenopathy, and periostitis (painful, nocturnal, tibial).
• Late (tertiary, after 6 months to years): destructive gummata of skin, nose, palate, and bones ("saber shin"), and rhinopharyngitis mutilans.
• Congenital infection is rare; cardiovascular and neurological disease are uncommon.

• Clinical diagnosis in endemic regions.
• Serology (RPR or VDRL and treponemal tests such as TPPA, FTA-ABS) reactive; indistinguishable from venereal syphilis, so history and epidemiology are essential.
• Dark field microscopy or PCR on mucosal lesions.
• Radiographs for bone involvement.
• Exclude venereal syphilis, yaws, leishmaniasis, TB, leprosy, and aphthous stomatitis.

• Benzathine penicillin G single IM injection of 1.2 million units (0.6 million units for children under 10 years).
• Alternative: azithromycin 30 mg/kg single oral dose (maximum 2 g) or doxycycline 100 mg twice daily for 14 days (for penicillin allergy, excluding pregnancy).
• Treatment of household members and close contacts; community health education on hygiene and avoiding shared utensils.
• Monitor with repeat serology at 3, 6, and 12 months.
• Screen for HIV and other STIs, and consider testing for venereal syphilis in sexually active individuals.