### Diagnosis Endemic non-venereal syphilis (*[[Treponema]]* *pallidum*). It is a chronic skin infection starting as painless mucous membrane ulcers then periostitis of the leg bones and gummas of the nose and soft palate. ### Epidemiologic Risks Person to person spread, especially among the poor by mouth-to-mouth contact or sharing of utensils. Mostly found the eastern Mediterranean and West Africa. As of 2019  spread as an STD in MSM in Japan. [^1] ### Microbiology *T*. *pallidum* subsp. *endemicum*. ### Empiric Therapy 1.2 IM [[Benzathine penicillin]] one time. ### Rationalizations [^1]: Kawahata T, Kojima Y, Furubayashi K, et al. [[Bejel]], a Nonvenereal Treponematosis, among Men Who Have Sex with Men, Japan. _Emerging Infectious Diseases_. 2019;25(8):1581-1583. doi:10.3201/eid2508.181690.