Yaws is a tropical infection of the skin, bones, and joints caused by the spirochete bacterium Treponema pallidum pertenue. The disease begins with a round, hard swelling of the skin, in diameter. The center may break open and form an ulcer. This initial skin lesion typically heals after 3–6 months. After weeks to years, joints and bones may become painful, fatigue may develop, and new skin lesions may appear. The skin of the palms of the hands and the soles of the feet may become thick and break open. The bones (especially those of the nose) may become misshapen. After 5 years or more, large areas of skin may die, leaving scars.
Yaws is spread by direct contact with the fluid from a lesion of an infected person. The contact is usually nonsexual. The disease is most common among children, who spread it by playing together. Other related treponemal diseases are bejel (T. pallidum endemicum), pinta (T. carateum), and syphilis (T. p. pallidum). The appearance of the lesions often diagnoses yaws. Blood antibody tests may be useful, but cannot separate previous from current infections. Polymerase chain reaction is the most accurate method of diagnosis.
No vaccine has yet been found. Prevention is, in part, done by curing those who have the disease, thereby decreasing the risk of transmission. Where the disease is common, treating the entire community is effective. Improving cleanliness and sanitation also decreases the spread. Treatment is typically with antibiotics, including azithromycin by mouth or benzathine penicillin by injection. Without treatment, physical deformities occur in 10% of cases.
Yaws is common in at least 13 tropical countries as of 2012. Almost 85% of infections occurred in three countries—Ghana, Papua New Guinea, and Solomon Islands. The disease only infects humans. Efforts in the 1950s and 1960s by the World Health Organization decreased the number of cases by 95%. Since then, cases have increased, but with renewed efforts to globally eradicate the disease by 2020. In 1995, the number of people infected was estimated at more than 500,000. In 2016, the number of reported cases was 59,000. Although one of the first descriptions of the disease was made in 1679 by Willem Piso, archaeological evidence suggests that yaws may have been present among human ancestors as far back as 1.6 million years ago.
Signs and symptoms Yaws primarily occurs in children, most frequently in those aged 6–10.
Yaws is classified as primary, secondary, and tertiary; this can be clinically useful, but infected patients often have a mix of stages.
Within 9–90 days (but usually about 21 days) of infection, a painless but distinctive "mother yaw" nodule appears. Initially reddened and inflamed, it may become a papilloma, which can then become an ulcer, possibly with a yellow crust. Mother yaws are most commonly found on the legs and ankles, and are rarely found on the genitals (unlike syphilis). The mother yaw enlarges and becomes warty in appearance. Nearby "daughter yaws" may also appear simultaneously. This primary stage resolves completely, with scarring, within 3–6 months. The scar is often pigmented.
The secondary stage occurs months to two years later (but usually 1–2 months later), and may thus begin when the mother wound has not yet healed. It happens when the bacterium spreads in the blood and lymph. It begins as multiple, pinhead-like papules; these initial lesions grow and change in appearance and may last weeks before healing, with or without scarring.
Secondary yaws typically shows widespread skin lesions that vary in appearance, including "crab yaws" (areas of skin of abnormal color) on the palms of the hands and soles of the feet (named for the crab-like gait they cause people with painful soles to assume). These may show desquamation. These secondary lesions frequently ulcerate and are then highly infectious, but heal after 6 months or more.
Secondary yaws affects the skin and bones. The most common bone-related problem is periostitis, an inflammation around the bone, which often occurs in the bones of the fingers and the long bones of the lower arms and legs, causing swollen fingers and limbs. This causes pain at night and thickening of the affected bones (periostitis). About 75% of infected children surveyed in Papua New Guinea reported joint pain. Swollen lymph nodes, fever, and malaise are also common.
A latent infection develops after primary and secondary yaws (and possibly, in some cases, without these phases). Within five years (rarely, within ten years), it can relapse and become active again, causing further secondary lesions, which may infect others. These relapse lesions are most commonly found around the armpits, mouth, and anus.
An estimated 10% of people with yaws were formerly thought to develop tertiary disease symptoms, but more recently, tertiary yaws has been less frequently reported.
Tertiary yaws can include gummatous nodules. It most commonly affects the skin. The skin of the palms and soles may thicken (hyperkeratosis). Nodules ulcerating near joints can cause tissue death. Periostitis can be much more severe. The shinbones may become bowed (saber shin) from chronic periostitis.
Yaws may or may not have cardiovascular or neurological effects; definitive evidence is lacking.
Rhinopharyngitis mutilans Rhinopharyngitis mutilans, also known as gangosa, is a destructive ulcerative condition that usually originates about the soft palate and spreads into the hard palate, nasopharynx, and nose, resulting in mutilating cicatrices, and outward to the face, eroding intervening bone, cartilage, and soft tissues. It occurs in the late stages of yaws, usually 5 to 10 years after the first symptoms of infection. This is now rare. Very rarely, yaws may cause bone spurs in the upper jaw near the nose (gondou); gondou was rare even when yaws was a common disease.
Cause Yaws is caused by infection with bacteria of the Treponema pallidum subspecies pertenue. The initial yaws wound contains infectious bacteria, which are passed onto others through skin-to-skin contact, typically during play or other normal childhood interactions. Early (primary and secondary) yaws lesions have a higher bacterial load, thus are more infectious. Both papillomas and ulcers are infectious. Infectivity is thought to last 12–18 months after infection, longer if a relapse occurs. Early yaws lesions are often itchy, and more lesions may form along lines that are scratched. Yaws may be evolving into less conspicuous lesions. After a new person is infected, an infectious papilloma will form within 9–90 days (on average 21 days).
T. pallidum pertenue has been identified in nonhuman primates (baboons, chimpanzees, and gorillas) and experimental inoculation of human beings with a simian isolate causes yaws-like disease. However, no evidence exists of cross-transmission between human beings and other primates, but more research is needed to discount the possibility of a yaws animal reservoir in nonhuman primates.
Diagnosis
Most often, the diagnosis is made clinically. Dark field microscopy of samples taken from early lesions (particularly ulcerative lesions) may show the responsible bacteria; the spirochaetes are only 0.3 μm wide by 6–20 μm long, so light-field microscopy does not suffice.
A microscopic examination of a biopsy of a yaw may show skin with clear epidermal hyperplasia (a type of skin thickening) and papillomatosis (a type of surface irregularity), often with focal spongiosis (an accumulation of fluid in a specific part of the epidermis). Immune system cells, neutrophils and plasma cells, accumulate in the skin, in densities that may cause microabscesses.
Warthin–Starry or Levaditi silver stains selectively stain T. pallidum, and direct and indirect immunofluorescence and immunoperoxidase tests can detect polyclonal antibodies to T. pallidum. Histology often shows some spatial features that distinguish yaws from syphilis (syphilis is more likely to be found in the dermis, not the epidermis, and shows more endothelial cell proliferation and vascular obliteration).
Blood-serum (serological) tests are increasingly done at the point of care. They include a growing range of treponemal and nontreponemal assays. Treponemal tests are more specific, and are positive for anyone who has ever been infected with yaws; they include the Treponema pallidum particle agglutination assay. Nontreponemal assays can be used to indicate the progress of an infection and a cure, and positive results weaken and may become negative after recovery, especially after a case is treated early. They include the venereal disease research laboratory (VDRL; requires microscopy) and rapid plasma (RPR; naked-eye result) tests, both of which flocculate patient-derived antibodies with antigens.
Serological tests cannot distinguish yaws from the closely related syphilis; no test distinguishing yaws from syphilis is widely available. The two genomes differ by about 0.2%. PCR and DNA sequencing can distinguish the two. There are also no common blood tests that distinguish among the four treponematoses: syphilis (T. p. pallidum), yaws (T. p. pertenue), bejel (T. p. endemicum), and pinta (T. carateum).
Haemophilus ducreyi infections can cause skin conditions that mimic primary yaws. People infected with Haemophilus ducreyi lesions may or may not also have latent yaws, and thus may or may not test positive on serological tests. This was discovered in the mid-2010s. It seems that a recently diverged strain of Haemophilus ducreyi has evolved from being a sexually transmitted infection to being a skin ulcer pathogen that looks like yaws.
Yaws has been reported in nonendemic countries.
Treatment Treatment is normally azithromycin by oral tablets, or less commonly by a course of other antibiotics, such as benzathine benzylpenicillin, an alternative for patients where azithromycin treatment failed, or tetracycline tablets. Penicillin has been the front-line treatment since at least the 1960s, but there is no solid evidence of the evolution of penicillin resistance in yaws.
The historical strategy for the eradication of yaws (1952–1964) was: Prevalence of clinically active yaws Treatment strategy Hyperendemic: above 10% Benzathine benzylpenicillin to the whole community (total mass treatment) Mesoendemic: 5–10% Treat all active cases, all children under 15, and all contacts of infectious cases (juvenile mass treatment) Hypoendemic: under 5% Treat all active cases and all household and other contacts (selective mass treatment)
Benzathine benzylpenicillin requires a cold chain and staff who can inject it, and there is a small risk of anaphylaxis. It was also not reliably available during the 2010s; there have been supply shortages.
In the 2010s, a single oral dose of azithromycin was shown to be as effective as intramuscular penicillin. Unlike penicillin, there is strong evidence that yaws is evolving antibiotic resistance to azithromycin; there are two known mutations in the bacterium, each of which can cause resistance and make the treatment ineffective. This has threatened eradication efforts.
Within 8–10 hours of penicillin treatment, bacteria can no longer be found in lesion biopsies. Primary and secondary lesions usually heal in 2–4 weeks; bone pain may improve within two days. If treated early enough, bone deformities may reverse and heal. Primary and secondary stage lesions may heal completely, but the destructive changes of tertiary yaws are largely irreversible.
If lesions do not heal, or RPR test results do not improve, this may indicate treatment failure or re-infection; the treatment is typically repeated. WHO guidelines say that any presumed treatment failures at 4 weeks require macrolide resistance testing.
Epidemiology
Yaws is typically found in humid tropical forest regions in South America, Africa, Asia, and Oceania.