Tertiary bejel is the final and most destructive stage of bejel, a nonvenereal treponemal infection caused by Treponema pallidum endemicum, a subspecies of the bacterium responsible for syphilis. Unlike syphilis, which is sexually transmitted, bejel is spread primarily through nonsexual skin contact, typically in children living in warm, arid, and impoverished regions, particularly in parts of the Middle East, North Africa, and arid regions of Asia.
Tertiary bejel emerges years after the initial infection when the disease has remained untreated, leading to severe tissue damage affecting the skin, bones, and cartilage.
Pathogenesis and Disease Progression
The progression of bejel follows a multistage course similar to syphilis:
- Primary Stage: Typically unnoticed, may involve minor mucosal lesions.
- Secondary Stage: Skin lesions and mucosal patches become prominent.
- Latent Phase: Asymptomatic but infectious period.
- Tertiary Stage: Destructive lesions, bone deformation, and disfigurement.
Causes and Transmission
Bejel is caused by Treponema pallidum endemicum, genetically similar to the syphilis pathogen but differing in transmission and geographic distribution.
Transmission
- Direct skin-to-skin contact with infectious lesions
- Shared utensils or grooming tools in endemic regions
- Most common in children under 15, especially in overcrowded or unsanitary living conditions
Clinical Features of Tertiary Bejel
Tertiary bejel is characterized by non-infectious but destructive gummatous lesions. These lesions affect deeper tissues and lead to serious disfigurement.
Common Symptoms:
- Gummatous Ulcers: Deep, destructive ulcers of the skin and soft tissue
- Bone Deformities: Especially in the nasal bone, tibia, and palate
- Gangosa: Severe necrosis of the soft palate and upper pharynx, resulting in nasal collapse and speech impairment
- Perforation of Palate or Nasal Septum
- Chronic osteitis and periostitis
These features may mimic leprosy or tertiary syphilis, requiring specific diagnostic protocols.
Diagnosis of Tertiary Bejel
Accurate diagnosis relies on clinical history, serological testing, and epidemiological context.
Key Diagnostic Methods:
- Serological Tests:
- Non-treponemal: VDRL, RPR
- Treponemal: FTA-ABS, TPPA
- Epidemiological Assessment:
- History of residence in or travel to endemic areas
- Family or community exposure
- Clinical Examination:
- Evaluation of skin, bone, and mucosal lesions
Because T. pallidum endemicum is indistinguishable serologically from T. pallidum pallidum, diagnosis is context-dependent.
Differential Diagnosis
Several other diseases present similar symptoms and must be ruled out:
| Condition | Key Features | Differentiating Factors |
|---|---|---|
| Tertiary Syphilis | Gummas, neurological symptoms | Sexually transmitted, often affects CNS |
| Leprosy | Skin lesions, nerve damage | Positive skin smears for Mycobacterium leprae |
| Yaws | Also treponemal, affects skin/bone | Caused by T. pallidum pertenue, different regions |
| Tuberculosis | Chronic ulcers, systemic symptoms | Presence of Mycobacterium tuberculosis |
Treatment of Tertiary Bejel
Timely treatment can halt disease progression and prevent further tissue damage, although structural damage may be irreversible.
First-line Treatment:
- Benzathine Penicillin G (IM injection)
- Adults: 2.4 million units once
- Children: Adjusted by body weight
Alternatives (if penicillin-allergic):
- Tetracycline
- Erythromycin
- Not as effective in late stages; penicillin remains the gold standard
Surgical Intervention:
- Reconstructive surgery for severe deformities, particularly in the nose and palate
- Speech therapy for functional rehabilitation
Public Health and Eradication Efforts
Bejel is targeted for eradication under the WHO’s Yaws Eradication Program, due to its treatability and limited zoonotic reservoir.
Challenges:
- Poor healthcare access
- Inadequate disease reporting
- Social stigma
- Asymptomatic early phases delay detection
Community-Based Strategies:
- Mass treatment campaigns using azithromycin
- Improved hygiene and sanitation
- Health education in endemic communities
Prevention of Tertiary Bejel
Community-Level Prevention:
- Public health education
- Improved access to early treatment
- Mass administration of antibiotics in high-burden areas
Individual-Level Prevention:
- Avoid sharing personal items (utensils, razors)
- Maintain hygiene
- Early medical attention for skin or mucosal lesions
Frequently Asked Questions:
Is tertiary bejel contagious?
No. While early stages are infectious, tertiary bejel lesions are non-infectious.
Can tertiary bejel be cured?
Yes, the infection can be eliminated with antibiotics, but tissue damage may be permanent if already present.
Is bejel the same as syphilis?
They are caused by closely related bacteria and follow similar stages but differ in transmission and geography.
Who is at risk of developing tertiary bejel?
Individuals living in endemic regions, particularly children who lack early treatment access.
How is tertiary bejel prevented?
Through early detection, antibiotic treatment, public health intervention, and improved hygiene practices.
Tertiary bejel represents the final, disfiguring stage of an otherwise preventable and treatable disease. While it is no longer widespread globally, endemic communities remain at risk due to limited healthcare access. Through combined efforts in diagnosis, treatment, public health education, and eradication initiatives, the burden of tertiary bejel can be effectively minimized. Prioritizing early intervention remains the most powerful strategy in preventing the devastating effects of this condition.
