Introduction

Definition of Bejel 

Bejel is an infectious disease commonly found in arid and warm climates, particularly in the Eastern Mediterranean and West Sub-Saharan Africa. The bacterial organism that causes Bejel is Treponema pallidum subspecies endemicum, which belongs to the same family as the treponema that causes venereal syphilis and shares identical morphological and antigenic characteristics. The main difference is that Bejel is not sexually transmitted; it typically spreads through non-sexual skin-to-skin contact or the use of common utensils. This condition currently poses a significant public health challenge in many developing countries.^1,2,3 

Importance of understanding transmission and risk factors 

Prevention and control of the disease

Bejel does not discriminate based on race or gender. The most at-risk population is children in poor health. Data shows that only 20% of cases involve adults, many of whom have been in contact with children. Approximately 25% of cases involve children six years old or younger, while 55% involve adolescents aged 16 years or younger.² 

To diagnose bejel, the patient's geographic history and laboratory results regarding the lesions (darkfield examination) are crucial. The bacterium Treponema is easy to identify. Additionally, if infected, fluid samples from the lesion area will test positive in both FTA-ABS (fluorescent treponemal antibody absorption) tests and VDRL (Venereal Disease Research Laboratory) tests. The main complication is differentiating bejel from venereal syphilis.² 

Public health implications

Public health implications focus on identifying cases and treating family members or individuals who have had close contact with the affected person. Early detection is crucial to prevent the disease from becoming chronic. The main challenge is that many prevention and treatment services are not always available to those in need. Some geographic areas simply do not have access to testing and treatment.^3,4

Transmission of Bejel

The mode of transmission of bejel has not yet been fully studied, so there are still uncertainties about how it is transmitted. However, it is clear that the disease is usually spread from child to child in unsanitary environments.³

Modes of transmission 

Direct contact

Bejel is contagious through skin contact and contact with lesions. It could also be spread through mucosal contact (e.g., kisses). However, this theory is not fully proven, mainly because there can be a very high number of spirochetes in the mouth, making them difficult to differentiate.^3,5

Indirect contact 

The main source of indirect transmission is shared utensils and contaminated personal items. This hypothesis is supported by the microscopic visualization of spirochetes on a vessel.⁵

Environmental factors 

High atmospheric humidity promotes the formation of lesions, which amplifies their oozing and infectiousness. Although the geographic regions where bejel is prevalent are typically characterized by dry climates, this treponema survives in moist areas, such as the mouth.⁶ 

Living conditions 

Living conditions play a significant role in the development of this disease. Many foci of bejel are found in areas where the socioeconomic environment is deteriorated and where many healthcare professionals lack sufficient knowledge of the disease.³

Incubation period 

The first symptoms appear 3 to 4 weeks after exposure. Initially, a papule (small bump) forms on the skin, usually on the lower extremities. Over time, the papule enlarges, ulcerates, and becomes crusted, sometimes with regional lymphadenitis. When the lesion heals, it develops into a secondary rash.⁷ 

Risk factors for Bejel

Socioeconomic factors 

The disease is especially concentrated in isolated, rural, and semi-urban communities living in unhygienic conditions and crowded into small spaces, such as huts or tents. Additionally, its economic impact on society is not well understood, as it primarily affects infants and children and is not typically fatal.⁷ 

Geographical distribution 

As mentioned earlier, bejel is currently characteristic of areas with warm and dry climates. Until 1960, this disease was still present in Bulgaria and Yugoslavia but was eradicated due to treatment programmes and social changes. A similar case occurred in the regions of Inner Carniola and Karst, both in Slovenia, where the disease was eradicated in the second decade of the 20th century. In 1987, the WHO and its Endemic Treponematoses Control Programme reported a significant increase in cases in sub-Saharan Africa, with 15-40% of children showing evidence of infection and 2-20% with initial lesions of endemic syphilis.

In 1988, a survey of people born in the desert among Bedouin tribes in the Middle East confirmed a 27% prevalence of the disease. Currently, endemic regions include the Turaiba area in Saudi Arabia, particularly among its nomadic and semi-nomadic tribes, as well as sub-Saharan Africa.^3,7 

Predominance in children 

This disease is not only transmitted within homes but also tends to spread in public places such as communities and schools. In the absence of infected adults in the home, the infection rate among children decreases. The infection can spread more easily when older children kiss their younger siblings, leading to many infections among other children in the family and previously uninfected adults.^8,9 

Public health infrastructure 

Access to healthcare services 

This disease is primarily found in areas with scarce resources. For many health professionals, it is either under control or not a priority due to the prevalence of other diseases and limited resources. Endemic treponematoses, in general, have become orphan diseases in many areas, with minimal political commitment to effectively include them in primary health care.^3,10 

Availability of preventive measures and treatments

Generally, a thorough analysis of clinical manifestations and the epidemiological context allows for a reliable diagnosis. However, in isolated areas, health professionals may be less familiar with the disease, which can lead to confusion with other illnesses and delays in treatment.³

Clinical manifestations and complications

Stages of Bejel

Primary stage: initial sores or lesions

Bejel, as mentioned earlier, usually begins in infants with mucous patches, generally in the mouth. This symptom often goes unnoticed or presents as stomatitis at the corners of the lips. This lesion is painless and sometimes heals on its own. However, if it persists, the next stage involves papulosquamous (scales and papules) and erosive papular lesions on the trunk and extremities, which are very similar to yaws.¹¹

Secondary stage: skin eruptions and mucosal patches 

In the secondary stage, mucosal patches remain common and are accompanied by bone pain caused by periostitis. Laryngitis in the form of papules can also occur. The stomatitis mentioned earlier may increase, or flat condylomas may appear in intertriginous areas (where two skin areas may touch).⁹

Tertiary stage: gummas and bone deformities

Two types of lesions occur: superficial nodular or tuberous lesions and deep gummatous lesions. While the nodular lesions have limited invasion of deeper tissues, the deep gummatous lesions consist of granulomatous syphilitic tissue that undergoes necrosis.⁹ 

Potential complications 

Chronicity and recurrence 

Common complications include disfigurement and scarring, which also increase the risk of contracting HIV. Chronic skin and soft tissue ulcers cause scarring and deformities, while bone and joint involvement can lead to further deformities and even disabilities. If left untreated, bejel can become increasingly chronic, with the timeline varying depending on the latency of the disease at different stages in each individual.^7,12

Impact on quality of life

Many patients respond well to antibiotics, and the prognosis in cases of no treatment is uncertain. Although it is true that in more advanced stages of the disease, patients may suffer neurological and/or cardiovascular sequelae, these are generally not as severe as those seen in other types of syphilis, such as tertiary syphilis.⁷ 

Prevention and control measures

Personal hygiene and sanitation 

Importance of cleanliness 

Small improvements in personal hygiene and lifestyle are key to changing the clinical course and transmission of bejel. Above all, it is important to wash hands with soap and water to minimize the spread of these bacteria and avoid sharing personal items that may come into contact with saliva, such as utensils, towels, or toothbrushes. It is also recommended to keep living spaces clean and promote appropriate cleaning and sanitation practices within each community. In high-risk communities, it is best to implement protective measures to prevent transmission.^3,13

Community health initiatives 

Education and awareness programmes 

It is crucial to educate people about the risks associated with this disease, its dangers, and the importance of preventive methods. This will help individuals seek medical advice promptly when an infection is suspected. It is estimated that there are up to four latent cases for each clinical case in areas of high endemicity.^8,13

Improving living conditions 

Social and economic improvements are the most effective method for combating bejel, as demonstrated by the eradication of this disease over the past 150 years, long before current treatments became available.³

Healthcare interventions 

Early diagnosis and treatment 

Doctors often examine a small sample of the skin sores under a microscope. When the lesion is in its early stages, benzathine penicillin G is usually administered intramuscularly. This treatment includes a follow-up for people close to the patient. Patients with later-detected manifestations are treated with two doses of penicillin every 7 days. After treatment, many patients become seronegative and are monitored to observe their progress. Individuals allergic to penicillin are given doxycycline or tetracycline. Lesions generally heal some time after treatment.^2,7,11

Summary

Bejel is an infectious disease caused by the bacterium Treponema pallidum. This bacterium is predominant in warm and arid regions, particularly in sub-Saharan Africa. Transmission primarily occurs through skin-to-skin contact or shared utensils. It primarily affects children living in communities with low socioeconomic capacity. Poor hygiene, combined with precarious living conditions, significantly increases the risk of contracting the disease.

Bejel is closely linked to poverty and unsanitary conditions, particularly in isolated rural areas. The disease progresses from initial mouth lesions to skin eruptions and, in advanced cases, to bone deformities and disfigurements. Prevention focuses on improving hygiene, raising public awareness, and ensuring early treatment, usually with penicillin, to control the spread of bejel.