Introduction

Bejel, also known as endemic syphilis, is a non-venereal bacterial infection caused by Treponema pallidum subspecies endemicum. The Treponema genus is also responsible for other non-venereal bacterial diseases like yaws (Treponema pallidum subspecies pertenue) and pinta (Treponema carateum), and venereal syphilis (Treponema pallidum subspecies pallidum). Therefore, they share many noteworthy similarities. Unlike venereal syphilis, bejel is transmitted primarily through non-sexual contact – direct skin-to-skin contact with the lesion, or indirectly, via shared objects such as utensils. The disease usually begins in childhood and is commonly transferred from one child to another.^1,2,3 

Bejel is characterised by multi-stage infection mainly involving the skin, bones and cartilage – early and late stages. The early stages are often infectious and can last up to five years before progressing to late stages. After an incubation period of 3 - 4 weeks,, symptomatic episodes may occur, marking the beginning of the early stages of the disease. The infection usually begins with patches of ulcers in the oral cavity that are painless, and therefore often missed. If left untreated, the infection progresses to late stage with involvement of the bones, joints and cartilage, causing osteitis and periostitis. In contrast to venereal syphilis, bejel infection is limited to skin and bones without affecting other organs or systems, and congenital transmission does not occur. This is particularly important to differentiate bejel from venereal syphilis.⁴

Bejel is found in dry, hot and temperate climates, often in poor rural communities living in low hygienic environments, such as the Sahel region in western Africa, parts of Botswana, Zimbabwe, and the Arabian Peninsula. The endemic disease is closely linked to poverty and a lack of access to social and health services, which leads to it being classified under the “neglected tropical diseases”. However, there have been a few case reports of bejel in non-endemic areas, including France, Canada, and Cuba, which are mostly imported cases. Nevertheless, geographical history is important in diagnosing bejel, alongside clinical examination of the lesions and laboratory tests.^5,6,7,8

Treatment options for bejel

Antibiotic therapy

The treatment of bejel is similar to that of venereal syphilis and other non-venereal bacterial diseases like yaws and pinta, which are all caused by similar bacteria of the Treponema species. Penicillin remains the mainstay treatment of bejel. A single dose of intramuscular injection of benzathine penicillin is given to effectively treat early lesions, and a second dose can be given a week later for late-stage lesions. The dose given for treatment of bejel is slightly lower than that of venereal syphilis, and differs for patients aged below and above 10 years. Alternatively, a single dose of oral azithromycin can be given if patients are allergic to penicillins. As azithromycin is linked to the development of antibiotic resistance, tetracycline derivatives (doxycycline) are another option for the treatment of bejel, although tetracyclines are not recommended for children under 8 years and pregnant women. Antibiotic therapy is effective in eradicating the bacteria and preventing further complications, but it does not reverse the damage that has occurred.⁹ 

Symptomatic treatment

To manage the symptoms of skin rashes and lesions, as well as bone pain, patients may be given painkillers or anti-inflammatory medications to reduce the pain and inflammation. Topical ointments can be used to soothe skin lesions whilst preventing secondary infections.

Preventive measures for bejel

Bejel is associated with low hygienic conditions; hence, maintaining good hygiene and sanitisation will reduce the occurrence and prevent transmission of bejel. As bejel is commonly seen in children, it is important to educate children to practice good hygiene at all times, both at home and outdoors. Good hygiene should be practised within the household by thoroughly cleaning shared or communal utensils to reduce the risk of transmission. Since the transmission of bejel is through direct contact with the lesion, a visible lesion should be cleaned and covered up to avoid unnecessary contact with another person. 

At the community level, interventions are necessary to improve overall public health and control the spread of bejel:

• A widespread education to raise awareness about bejel and its symptoms could help the community to identify the infection at an early stage and promptly seek medical treatment to prevent further complications
• Collaborating with community leaders, schools, religious institutions and local media to spread the information about bejel and promote prevention initiatives
• Implementing screening programs in the community to identify and treat infected individuals early
• Regular surveillance helps monitor the prevalence of bejel and assess the effectiveness of prevention strategies
• Educating local healthcare workers to recognise the signs and symptoms of bejel, ensuring they can provide appropriate care and educate their communities
• Outreach programs, especially in remote or rural areas, can help these vulnerable communities to receive the necessary access to healthcare
• Ensuring the community has access to healthcare facilities, including antibiotictreatment

Maintaining hydration and good nutrition are crucial in order to maintain a healthy immune system. A healthy immune system also promotes quick recovery and prevents re-infection.

FAQs

Are bejel and syphilis the same?

Bejel is endemic syphilis, while syphilis usually refers to venereal syphilis, which is a sexually transmitted disease. They differ in the mode of transmission and the clinical manifestations of the lesions. 

How do I differentiate bejel and syphilis?

Although bejel presents with lesions that are similar to syphilis, the diagnosis of bejel usually comes after thorough history checking and clinical examinations of the lesions. Bejel mainly affects the skin and bones (late-stage) in contrast to venereal syphilis, which often involves other systems, such as the central nervous system and cardiovascular system.

Can bejel be cured?

Yes. Antibiotic therapy (usually one dose) is effective in eradicating the infection. However, re-infection can occur if preventive measures are not taken.

Summary

Bejel is a chronic bacterial infection, which is also known as endemic syphilis. Bejel mainly affects children in rural areas with dry and hot climates. The skin and bones are the only organs involved in bejel. Bejel can be treated effectively with antibiotics, primarily penicillin, although azithromycin and tetracycline derivatives have also been shown to be effective. Good hygiene practice is needed to prevent bejel and public health awareness aids in controlling the spread of the disease.