Syphilis

Aka: Syphilis, Treponema pallidum

1. See Also
   1. Sexually Transmitted Disease
   2. Primary Syphilis
   3. Secondary Syphilis
   4. Latent Syphilis
   5. Tertiary Syphilis
   6. Congenital Syphilis
   7. Syphilitic Gumma
   8. Cardiovascular Syphilis
   9. Neurosyphilis
   10. Syphilis Testing
   11. Genital Ulcer
2. Epidemiology
   1. Resurgence of Syphilis since HIV epidemic onset in 1980s
   2. Syphilis Incidence in U.S. (primary and secondary) is increasing
      1. 2000: 2.1 cases per 100,000 persons
      2. 2007: 3.8 cases per 100,000 persons
3. Etiology
   1. Caused by Spirochete Treponema pallidum
4. Risk factors: Cohorts with highest Prevalence in U.S.
   1. Homosexual men
   2. Males
   3. Southern and urban centers
   4. African americans
5. Stages
   1. Primary Syphilis
   2. Secondary Syphilis
   3. Latent Syphilis
   4. Tertiary Syphilis
      1. Syphilitic Gumma
      2. Cardiovascular Syphilis
      3. Neurosyphilis
6. Signs
   1. See Neurosyphilis
   2. Chancre (ulcer in Primary Syphilis)
      1. Single, painless, well-demarcated ulcer
      2. Clean base
      3. Indurated border
   3. Gumma (lesion in Tertiary Syphilis)
      1. Diffusely distributed soft ulcerative lesions, with firm necotic center
   4. Lymph
      1. Mildly tender inguinal lyphadenopathy (Secondary Syphilis)
7. Differential Diagnosis: Syphilis Chancre or condyloma
   1. See Genital Ulcer
   2. Genital Herpes
   3. Chancroid
   4. Venereal Wart
   5. Lymphogranuloma venereum
8. Diagnosis
   1. See Syphilis Testing
9. Precautions
   1. Syphilis requires a high index of suspicion
      1. Widely variable presentations
      2. Resurgence in the last 10 years
      3. Insidious and delayed onset with painless primary lesions that may easily be missed
10. Management
    1. Incubation stage (post-exposure prophylaxis)
       1. Ceftriaxone 250 mg IM and
       2. Doxycycline 100 mg for 14 days
       3. Azithromycin (Zithromax) 1 gram orally for 1 dose
    2. Primary, secondary, early latent (under one year)
       1. Benzathine Penicillin G
          1. Adult: 2.4 MU IM for 1 dose
          2. Child: 50,000 units/kg IM for 1 dose (max: 2.4 MU)
       2. Aqueous Procaine Penicillin G 0.6 MU IM qd for 8 days
       3. Jarisch-Herxheimer Reaction may occur
          1. Acute febrile reaction in first 24 hours of Syphilis treatment
       4. If Penicillin allergic
          1. Ceftriaxone 1 gram IM or IV for 10-14 days
          2. Tetracycline 500 mg orally four times daily for 14 days
          3. Doxycycline 100 mg orally twice daily for 14 days
          4. Azithromycin 2 grams orally once
             1. High risk of resistance
             2. Use only in Penicillin allergic patients who can not take doxycyline, Minocycline or Ceftriaxone
             3. Avoid in pregnant women or men who have sex with men
    3. Late latent, Cardiovascular Syphilis (duration over 1 year)
       1. Benzathine Penicillin G 2.4 MU IM qWeek for 3 weeks
       2. If Penicillin allergic
          1. Tetracycline 500 mg PO qid for 4 weeks
          2. Doxycycline 100 mg PO bid for 4 weeks
    4. Neurosyphilis
       1. See Neurosyphilis
    5. Pregnancy
       1. Treat with Penicillin as above
       2. Desensitize and treat with Penicillin if allergic
    6. Congenital Syphilis
       1. CDC STD management booklet
          1. http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
11. Follow-up: 6 months after treatment (Stage 1-2)
    1. Repeat quantitative nontreponemal test titers at 6-12 months after treatment (all patients)
       1. Expect a four-fold decrease in RPR or VDRL titers over subsequent 3-6 months following treatment
       2. Four-fold increase in titers over prior level suggests recurrent Syphilis and these patients should be re-treated
       3. Decrease in titers may be slower in patients who have had more than one Syphilis infection
       4. Seronegative conversion may occur if original titers were low or in cases treated early (stage 1-2)
    2. Repeat clinical evaluation
       1. Persistent symptoms and signs despite treatment should prompt Syphilis re-treatment
12. References
    1. (2002) MMWR Morb Mortal Wkly Rep 51(RR-6):18-30
    2. Brown (2003) Am Fam Physician 68(2):283-90
    3. Hook (1999) Ann Intern Med 131:434-7
    4. Mattel (2012) Am Fam Physician 86(5): 433-40
    5. Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110