A recording of his excellent presentation is available HERE.
For those of you who want the notes, here are my notes:
Epidemiology:
- Before 2013, cases of syphilis in the US were generally concentrated in men who have sex with men (MSM)
- From 2013-2018, there has been increase of 170% primary and secondary syphilis diagnosis in women AND rising rates in black/Latinx populations
- There is a high rate of co-infection w/HIV (42% MSM with syphilis also have HIV)
- In 2019, 129K cases of syphilis in the US (MSM and MSMW), 1870 cases reported of congenital syphilis (unfortunately more common in BIPOC mothers)
- In SoCo, as well, rates have been increasing, similarly transitioning from primarily a disease in MSM to a wider category of folks, including more women, homeless, persons who inject drugs
What is syphilis?
- A spirochete infection caused by treponema pallidum
- Multiple stages of syphilis can be confusing (see graphic below from Emory)
- The incubation period 9 days-3 months (can be asymptomatic)
- Neurosyphilis, ocular syphilis and otic syphilis can happen at ANY time during infection (should have low threshold to test for these)
Primary syphilis: 3-90 days after exposure, painless chancre, round and firm, can appear anywhere, generally 3 weeks after infection, heal on own in days/weeks, place where chancre appears is where exposure occurred (e.g. anus, vagina, penis). Gets missed, people don't notice because it doesn't hurt!
Secondary syphilis: 3-6 months after initial infection: "bigger rashes", more widespread (hands, feet, trunk, tongue, hair loss)
Tertiary syphilis: years to decades after exposure, "the great imitator", can show up in any tissues: cardiovascular, skin, bone, etc
Early latent: asymptomatic, <12 months of exposure
Late latent: asymptomatic infection >12 months of exposure, "syphilis of unknown duration"
Neurosyphilis: CNS infection (meningitis), general paresis, tabes dorsalis
Ocular syphilis: vision loss, blurry vision, eye pain, redness
Otic syphilis: sensorineural hearing loss, tinnitus, vertigo
Transmission:
- Primary syphilis is VERY transmittable (lots of treponemes in primary chancres-- any surface is vulnerable), likelihood of transmission is ~30%
- As you move through stages, you become less and less infectious, can definitely still transmit but less than primary
- Syphilis is also one of TORCHES infections, the spirochete crosses the placenta very readily
Diagnosis:
- Two types of tests:
- Non-treponemal test: tests for cardiolipin cholesterol-lecithin antigen (RPR, VDRL), always presented as titers
- Treponemal test: detection of Ab against Ag. once positive, will always test positive (FTA-ABS, TPPA)
- Two methods for testing, decision which algorithm to use is based on prevalence. Generally thought higher prevalence area should use reverse testing algorithm
- Traditional (see image) starts with RPR, reflex to TPPA confirmation
- Reverse (see image), do the opposite (start with TPPA), if that tests positive, reflexes to RPR)
- Once a patient is positive, Treponemal tests will ALWAYS be positive, so you always need RPR and titers
- Do note, you can have false negative RPR in latent period and upon appearance of chancre 1-3 weeks (e.g. if you are testing "too early", if you see a chancre, treat treat treat)
- Dx of neurosyphilis requires high clinical suspicion and low threshold for doing LP and getting CSF: test for protein, WBC, CSF-VDRL (which has poor sensitivity, 70% can test negative)
Treatment
Penicillin is ALWAYS the treatment (see chart above for details)
- Don't forget to get an RPR on the day of treatment (to get baseline)
- If a patient reports contact with anyone with syphilis in the last 90 days, treat empirically!
- including partner treatment!
- www.dontspreadit.com (anonymous texting about exposure)
- Primary, secondary, early latent (<12 months): PCN 2.4 million units IMx 1
- Late latent (>12 months), unknown duration of tertiary with normal CSF: need to be treated with IM injections x 3 (one week apart)
- Neuro/ocular/otic syphilis: treatment is IV PCN 10-14 days (usually initial hospitalization)
- If a patient has PCN allergy, desensitization and treatment with PCN is still recommended (JAMA article on PCN desensitization available HERE)
- Follow-up testing is KEY:
- for primary/secondary, early latent, retest with RPR at 6, 12 month (looking for 4x decrease in titer)
- for late latent, unknown, you should retest at 6, 12, and 24 months
- RPR baseline will be your guideline to determine if someone has been reinfected (4x increase demonstrates reinfection)
Questions about staging/treatment, can always call: Team Vida 707-583-8823 or SoCo Health Department 707-565-4566
Congenital Syphilis:
- complex diagnosis and treatment algorithms (see diagram from California DPH below)
- steady rise of congenital syphilis since 2012, 400% increase since 2012
- syphilis readily crosses placenta or via contact with chancre during delivery
- can affect ALL organs of the body, can lead to infant death and miscarriage
- wide clinical presentation: < 2 year old, usually presents by 5w-3 months of age, 60-90% will be symptomatic
- sx include hepatomegaly, jaundice, rhinitis ("snuffles"=white discharge, more severe than common cold, mucous discharge VERY infectious because lots of treponemes in them), rash, generalized LAD, skeletal abnormalities
- Treatment: IV PCN 50K units/kg q8 hours x 1 week, then q12 hours OR PCM IM x daily x 10 days
- Evaluation: neurodevelopmental, hearing, eye, serologic testing with RPR until negative or 4x decrease (usually non-reactive by 6 months)
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| https://californiaptc.com/in-the-news/new-tool-for-clinicians-unveiled-to-ensure-appropriate-treatment-of-congenital-syphilis/ |
Screen for STIs!
Screen all sexually active patients for HIV, RPR, GC/CT (including swabbing every site they use to have sex, including mouth, vagina, rectal)
Other STIs predict HIV risk (see infographic)
Offer partner treatment always
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| https://californiaptc.com/wp-content/uploads/2017/03/Slide7.jpg |
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