Back to Basics: Syphilis

Mon, 06/21/2021 - 5:00am
Author: 
Danielle Kovalsky, MD
Editor: 
Alexis Pelletier-Bui, MD

Back to Basics: Syphilis

By: Danielle Kovalsky, MD

 

Primary Syphilis:

  • Typically presents around 21 days after exposure
  • Presents with a chancre: PAINLESS ulcer with induration that can present on any area of sexual contact (including the oral mucosa).  Typically lasts 3-6 weeks and resolves spontaneously.  Can present with regional lymphadenopathy.  No constitutional symptoms.  Some patients never present with chancre.

Secondary Syphilis:

  • Typically presents 3-6 weeks following the end of the primary stage
  • Classic rash: red-pink, papular, does not spare the palms and the soles
  • Lymphadenopathy
  • Alopecia: described as “moth eaten” due to patchy appearance
  • Non-specific symptoms: fever, sore throat, headache
  • Ocular findings: most common = uveitis

Tertiary Syphilis:

  • Typically presents 3-20 years after initial infection
  • Nervous system manifestations: meningitis, dementia, neuropathy, tabes dorsalis
  • Cardiovascular system manifestations: thoracic aortic aneurysms, aortic valve regurgitation
  • Gummatas: rare, granulomatous lesions that can present anywhere in the body (i.e. skin, bones, internal organs)

There has been a rise in cases of syphilis in the U.S.

  • From 2.1/100,000 in 2001 to 10.8/100,000 in 2018 (CDC)
  • Higher rise in MSM and women

Who should be tested for syphilis?

  • Symptomatic patients
  • Asymptomatic patients with a partner diagnosed with syphilis (treat empirically), sexually active men who have sex with men (MSM), HIV-infected individuals, or any patient with high risk sexual behavior
    • "High risk” behavior includes previous diagnosis of STI, people who exchange sex for money or drugs, indvididuals with multiple partners not using condoms

Diagnosis

  • Nontreponemal tests: Venereal Disease Research Laboratory test (VDRL) and Rapid Plasma Reagin (RPR)
    • Detect nonspecific antibodies to cardiolipins that are released as a result of infections
    • Screening tests
    • Can also be used to assess disease activity and response to treatment
    • Will likely not be positive until 1-4 weeks post-chancre
  • Treponemal Antibody test:
    • Fluorescent Treponemal Antibody Absorption Test (FTA-ABS)
    • Specific test
    • Will be reactive for life regardless of disease activity or treatment
    • Typically used as a confirmatory test, however, cheaper costs increasing use as screening test

Treatment

  • Primary/Secondary Syphilis
    • 2.4 million units IM Penicillin G benzathine in a single dose
    • Penicillin allergy? Doxycycline BID for 2 weeks or ceftriaxone 1-2 g IM/IV 10-14 days
    • Penicillin allergy and pregnant? Require penicillin desensitization
  • Tertiary Syphilis
    • 2.4 million units IM Penicillin G weekly for 3 weeks
    • Repeat testing at 6 and 12 months
  • Jarisch-Herxheimer reaction: acute febrile reaction that presents with myalgias and headache within 24 hours of treatment of syphilis. It is self-limited and can be treated with NSAIDs. Warn your patients!

 

References:

Clark EG, Danbolt N. The Oslo study of the natural course of untreated syphilis: An epidemiologic investigation based on a re-study of the Boeck-Bruusgaard material, Med Clin North Am. 1964;48:613. 

Clement ME, Okeke NL, Hicks CB. Treatment of syphilis: a systematic review. JAMA. 2014 Nov;312(18):1905-17. 
Kennedy JL, Barnard JJ, Prahlow JA. Syphilitic coronary artery ostial stenosis resulting in acute myocardial infarction and death. Cardiology. 2006;105(1):25. 
Rosahn PD. Autopsy studies in syphilis. 649 Information supplement #21, J Venereal Disease; U.S. Public Health Service Venereal Disease Division, Washington, DC 1947.
Serrano KD. (2020). Sexually Transmitted Infections. In Tintinalli's Emergency Medicine: A comprehensive study guide. (9th ed., pp. 1018-1019). New York, NY: McGrawl-Hill Education.
Sparling PF. Natural history of syphilis. Sexually Transmitted Diseases, Holmes KK, Mardh PA, Sparling PF, et al (Eds), McGraw-Hill, New York 1990. p.213.

US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, García FA, Gillman MW, Harper DM, Kemper AR, Krist AH, Kurth AE, Landefeld CS, Mangione CM, Phillips WR, Phipps MG, Pignone MP . Screening for Syphilis Infection in Nonpregnant Adults and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2016 Jun;315(21):2321-7. Hicks, C. (2020, November 05).