STD
Syphilis
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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,
Scaling
Macula
r 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
Plaque
s)
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 Ulcer
s (
Chancre
of
Primary Syphilis
) facilitate
HIV Transmission
Chancre
s are laden with
Lymphocyte
s 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]
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