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Syphilis
Aka: Syphilis, Treponema pallidum
- See Also
- Sexually Transmitted Disease
- Primary Syphilis
- Secondary Syphilis
- Latent Syphilis
- Tertiary Syphilis
- Congenital Syphilis
- Syphilitic Gumma
- Cardiovascular Syphilis
- Neurosyphilis
- Syphilis Testing
- Genital Ulcer
- Epidemiology
- Resurgence of Syphilis since HIV epidemic onset in 1980s
- Worldwide: 5 Million new cases per year
- Syphilis Incidence in U.S. (primary and secondary) is increasing
- 2000: 2.1 cases per 100,000 persons (5979 new cases in U.S.)
- 2005: 2.9 cases per 100,000 persons (8724 new cases in U.S.)
- 2010: 4.5 cases per 100,000 persons (13,774 new cases in U.S.)
- 2014: 6.3 cases per 100,000 persons (19,999 new cases in U.S.)
- Men account for 91% of cases (of whom 83% are Gay Men)
- 2015: 8.0 cases per 100,000 persons (23,872 new cases in U.S.)
- 2018: 10.8 cases per 100,000 persons (35,063 new cases in U.S.)
- Gender
- Males account for 90% of cases
- Men who have Sex with Men account for 82% of cases in men
- HIV and Syphilis infection are associated
- Reinfections
- Reinfection accounts for 15-20% of new Syphilis cases each year
- Causes
- Caused by Spirochete Treponema pallidum
- In addition to Syphilis, Treponema pallidum also causes yaws and pinta
- Pathophysiology
- Transmission via mucous membranes, non-intact skin, transfusions, and vertical transmission (transplacental)
- Risk factors: Cohorts with highest Prevalence in U.S.
- HIV Infection
- Men who have Sex with Men (most common)
- Incarceration
- Sex Worker History
- Males
- Southern and Western U.S,
- Urban centers
- Age 20 to 35 years (esp. under age 30 years old)
- Race and ethnicity
- African americans
- Hispanics
- American Indians
- Alaskan and Hawaiian natives
- Pacific Islanders
- Signs: By Stage
- Primary Syphilis
- Solitary Chancre (hallmark ulcer of Primary Syphilis) - genital lesion in 95% of cases
- Single, painless, well-demarcated ulcer
- Clean base
- Indurated border
- Nonsuppurative, mildly tender Regional Lymphadenopathy (uncommon)
- Secondary Syphilis
- Nickel and dime-size pale, pink to red discrete round, ScalingMacular to papular lesions
- Distributed over trunk, flexors, palms, soles
- Condyloma Lata (painless, wart-like lesions)
- Distributed over mouth, genitalia and intertriginous areas (perineum, axilla, between toes)
- Syphilitic Alopecia (Alopecia with moth-eaten appearance)
- Latent Syphilis
- Latent, asymptomatic period of 3-20 years
- Infectious only in pregnancy and Blood Transfusion
- One third will progress to Tertiary Syphilis
- Tertiary Syphilis
- Syphilitic Gumma (granulomas and Psoriasis-like Plaques)
- Diffusely distributed soft ulcerative lesions, with firm necotic center
- Cardiovascular Syphilis (thoracic aneurysm)
- Neurosyphilis (Tabes Dorsalis, Meningitis, Dementia)
- Differential Diagnosis
- See Genital Ulcer
- See Hand Dermatitis
- See Alopecia
- See Sexually Transmitted Infection
- Syphilis Chancre or Condyloma Lata
- Genital Herpes
- Chancroid
- Venereal Wart
- Lymphogranuloma venereum
- Labs
- See Syphilis Testing
- HIV Screening
- Other Sexually Transmitted Infection sceening
- Gonorrhea PCR
- Chlamydia PCR
- Trichomonas PCR (or wet prep)
- Precautions
- Syphilis requires a high index of suspicion
- Widely variable presentations
- Resurgence in the last 10 years
- Insidious and delayed onset with painless primary lesions that may easily be missed
- Management
- Incubation stage (Post-exposure Prophylaxis)
- Ceftriaxone 250 mg IM and
- Doxycycline 100 mg for 14 days
- Azithromycin (Zithromax) 1 gram orally for 1 dose
- Primary, secondary, early latent (under one year)
- Benzathine Penicillin G (Bicillin LA)
- Adult: 2.4 MU IM for 1 dose
- Child: 50,000 units/kg IM for 1 dose (max: 2.4 MU)
- Aqueous Procaine Penicillin G 0.6 MU IM daily for 8 days
- Jarisch-Herxheimer Reaction may occur
- Acute febrile reaction (due to Spirochete lysis) in first 24 hours of Syphilis treatment
- Manifests as fever, Headache, rash exacerbation
- If Penicillin allergic
- Ceftriaxone 1 to 2 gram IM or IV for 10-14 days
- Tetracycline 500 mg orally four times daily for 14 days
- Doxycycline 100 mg orally twice daily for 14 days
- Avoid Azithromycin
- Previously dosed at Azithromycin 2 grams orally once
- High risk of resistance (esp. pregnancy, Men who have Sex with Men)
- Was used only if Penicillin allergic and unable to take doxycyline, Minocycline or Ceftriaxone
- Late latent, Cardiovascular Syphilis (duration over 1 year)
- Benzathine Penicillin (Bicillin LA) G 2.4 MU IM qWeek for 3 weeks
- If Penicillin allergic
- Tetracycline 500 mg PO qid for 4 weeks
- Doxycycline 100 mg PO bid for 4 weeks
- Neurosyphilis
- See Neurosyphilis
- Pregnancy
- Screen all patients in early pregnancy (and consider rescreening in third trimester)
- Treat with Penicillin as above
- If Penicillin allergic, admit, desensitize and treat with Penicillin
- Congenital Syphilis
- CDC STD management booklet
- http://www.cdc.gov/mmwr/pdf/rr/rr5912.pdf
- Sexual partners
- Treat all sexual contacts from prior 90 days
- Follow-up: 6 months after treatment (Stage 1-2)
- Repeat quantitative nontreponemal test titers at 6 and 12 months after treatment (all patients)
- Expect a four-fold decrease in RPR or VDRL titers over subsequent 3-6 months following treatment
- Four-fold increase in titers over prior level suggests recurrent Syphilis and these patients should be re-treated
- Decrease in titers may be slower in patients who have had more than one Syphilis infection
- Seronegative conversion may occur if original titers were low or in cases treated early (stage 1-2)
- Repeat clinical evaluation
- Persistent symptoms and signs despite treatment should prompt Syphilis re-treatment
- Complications
- Unteated pregnancy (even if acquired up to 4 years before pregnancy)
- Fetal infection risk 80%
- Stillbirth or Miscarriage: 40%
- Untreated Secondary Syphilis
- Lues Maligna (Ulceronodular Syphilis, Malignant Syphilis)
- Severe form of Secondary Syphilis (especially in immunosuppressed patients)
- Hepatitis
- Periostitis
- Nephropathy
- Uveitis or Iritis
- Untreated Tertiary Syphilis
- Thoracic Aortic Aneurysm (from ascending aortitis)
- Neurosyphilis complications
- HIV Transmission
- Syphilis related Genital Ulcers (Chancre of Primary Syphilis) facilitate HIV Transmission
- Chancres are laden with Lymphocytes which allow for both HIV Transmission and entry
- Prevention
- Screen all high risk patients at least annually
- Screen more often in Men who have Sex with Men, not in monogamous relationships
- Screen in pregnancy
- Screen at least once in pregnancy (typically with initial pregnancy labs)
- Repeat screening in high risk groups and in regions of high syphilis Prevalence
- References
- Green, Cohen, Billington (2016) Crit Dec Emerg Med 30(11): 4-10
- (2002) MMWR Morb Mortal Wkly Rep 51(RR-6):18-30 [PubMed]
- Brown (2003) Am Fam Physician 68(2):283-90 [PubMed]
- Hook (1999) Ann Intern Med 131:434-7 [PubMed]
- Mattel (2012) Am Fam Physician 86(5): 433-40 [PubMed]
- Ricco (2020) Am Fam Physician 102(2): 91-8 [PubMed]
- Workowski (2010) MMWR Recomm Rep 59(RR-12): 1-110 [PubMed]