Transmission
What is the organism that causes syphilis?
Treponema pallidum (a spirochete)
How often do you test for syphilis in pregnancy?
1. First prenatal visit
2. ~28 weeks
3. At birth
**Now universally recommended to test 3 times by ACOG, due to rising prevalence of syphilis nationwide and congenital syphilis
What are the two most infectious stages of syphilis?
Primary and secondary stages (both early stage)
Name treatment for all stages of syphilis
1. Primary, secondary and early latent: 2.4 million units of IM benzathine penicillin G once
**Some may administer 4.8 million units " over 2 weeks to reduce risk of congenital syphilis due to high treponemal burden in early syphilis
2. Late latent or unknown duration: 2.4 million units of IM benzathine pen G x3 (one per week, within 7-9 days)
*If allergic to pencillin, then need to desensitize
*Ideally, given 30 days prior to delivery
Doxycycline 100 mg BID x14 days for early stage, 28 days for late latent
A chancre is an indication of what stage of syphilis?
Primary syphilis
Deep, ulcerated lesion, limited or no pain. Kissing lesions. From delayed hypersensitivity response to infecting spirochetes. May be singular or multiple. Consider swabbing for HSV for workup.
What do you need to diagnose syphilis
Reactive treponemal (always positive in person w/syphilis) AND non-treponemal (positive in active disease) tests
Describe the time periods of primary and secondary stages of syphilis
Primary: Appears about 10-90 days after infection (up to 3 weeks). Chancre
Secondary: 3-6 weeks after infection
*Chancre and rashes will resolve regardless of treatment
You suspect a chancre on exam and the patient is pregnant. What do you do?
Presumptive treatment is indicated, whether serologic testing is available or conclusive.
Patients with primary syphilis may have negative or non-reactive nontreopnemal tests in up to 10% of cases
How do you diagnose neurosyphilis?
CSF tap
*Same for tertiary syphilis. If suspected, CSF exam is warranted regardless of pregnancy status
What're we having for lunch today?
:)
Name two treponemal tests
FTA-ABS (indirect fluorescent treponemal antibody absorption)
TP-PA (T pallidum particle agglutination)
CIA/EIA (Chemiluminescence Immunoassay and Enzyme Immunoassay)
What is tertiary syphilis?
When syphilis affects different organ systems: Includes aortic aneurysm, gummatous lesions (skeletal, mucosal, skin), dementia/psychosis
occurs 10-30 years after infection begins
What is adequate treatment response?
Fourfold decrease in titer (ex. 1:64 to 1:8)
*Make sure this is the same lab and test!
In a patient who was adequately treated for syphilis with appropriate decrease in titers, what is evidence suggests reinfection?
Fourfold increase in serologic response (ex. 1:2 to 1:8)
Occasionally a non-treponemal test can alternate between nonreactive and low reactive (1:1 and 1:2 without reinfection)
Consider: pre-treatment titer, whether serologic response was documented, time since prior treatment, and whether re-exposure to infected partner is likely
What is the % risk of vertical transmission in early syphilis?
50% - 80%
Risk of "assuming" late latent syphilis and failing to make a correct dx of early syphilis also deprioritizes partner services for disease intervention specialists, who are trained to prioritize locating contacts of patients with early syphilis for testing and treatment
Name the two non-treponemal antibody tests
RPR (rapid plasma reagin) or VDRL (venereal disease research laboratory)
Detects antibody to lipoidal antigens from both damaged host cells and spirochetes
Name the two stages of latent syphilis and definitions.
1. Early latent: infection that occurred within the previous 12 months but without obvious primary or secondary lesions at time of diagnosis (ex. pt tells you generalized palmar rash that resolved within the past year)
2. Late latent: asymptomatic patient with reactive tests, no history of prior treatment, and no recent exposure to someone with early syphilis
AKA latent syphilis of unknown duration
Following treatment for syphilis in a pregnant patient, what is the soonest you may re-draw the titer for treatment response?
8 weeks
For those with high initial titers (1:8), will typically see change. However, if low initial titer or treatment late in pregnancy, may not see change in titers until 6-12 months later
Symptoms of congenital syphilis?
Blueberry muffin rash associated with thrombocytopenia
Desquamating skin rash
On xray, long bones with moth-eaten femoral metaphysis
Name at least 3 symptoms of secondary syphilis
Generalized maculopapular rash (esp on hands and feet)
Oral mucous patches
Condyloma lata
Alopecia
Lymphadenopathy
Fever, malaise, pharyngitis
Secondary syphilis is when spirochetes spread through blood and lymph to sites distant from initial site of infection. Chancres may also recur or persist during secondary syphilis, and sensitivity of RPR/VDRL are approx 100% in secondary syphilis, and titers tend to be very high
What are symptoms of the Jarisch-Herxheimer reaction?
Fever, chills, myalgia, headache, and hypotension caused by treatment for syphilis (Due to massive surge of inflammatory cytokines from all the proteins the dead spirochetes spill)
*more common in early syphilis
*Self resolves over 24 hours
When does neurosyphilis occur?
AT ANY TIME IN COURSE OF INFECTION!!
Symptoms: meningitis, uveitis/retinitis, stroke-like symptoms
So does otosyphilis (ringing in ears, hearing loss) and ocular syphilis (vision changes)
What medications do you use for people allergic to Penicillin?
Doxycycline & Ceftriaxone
Ultrasound findings of congenital syphilis?
Placentomegaly
Hepatomegaly
Ascites or nonimmune hydrops
Anemia detected by MCA doppler studies