Syphilis infection;It is a sexually transmitted infection (STI) that spreads through direct contact with syphilis sores. It caused by Treponema pallidum. The disease has been divided into three stages based on clinical findings. This helps in guiding treatment and follow-up.
Primary syphilis infection – ulcers or chancre at the infection site usually at genital area.
Secondary syphilis – manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy.
Tertiary syphilis symptoms includes
- Cardiac sysptoms
- Gummatous lesions,
- Tabes dorsalis and
- General paresis
Latent infection –
- It lack clinical manifestations which are detected by serologic testing.
- Latent syphilis acquired within the preceding year is referred to as early latent syphilis.
- All other cases of latent syphilis are late latent syphilis or syphilis of unknown duration.
Occurs when treponema pallidum infect central nervous system. Early neurological clinical manifestation include;
- Cranial nerve dysfunction
- Stroke/cerebral vascular accident.
- Acute altered mental status and
- Auditory or ophthalmic abnormalities. All the above symptoms may take few months or even years of infection.
Doctor/Clinician may order one of the following tests to be done on you in case he suspect syphilis.
- Darkfield examinations and tests to detect T. pallidum directly from lesion exudate or tissue.This is definitive methods for diagnosing early syphilis.
- PCR test. This helps to detect Traponema pallidum DNA.
- Nontreponemal test. such as Venereal Disease Research Laboratory [VDRL] or Rapid Plasma Reagin [RPR].
- Treponema test. flourescent trponemal antibody absorbed [FTA-ABS].
Penicillin G, administered parenterally, is the preferred drug for treating persons in all stages of syphilis. The preparation used include; benzathine, aqueous procaine, or aqueous crystalline.The dosage, and length of treatment depend on the stage and clinical manifestations of the disease. Treatment for late latent syphilis and tertiary syphilis require a longer duration of therapy. This is because organisms theoretically might be dividing more slowly.
Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis in any stage who report penicillin allergy should be desensitized and treated with penicillin.
Is an acute febrile reaction frequently accompanied by headache, myalgia, fever, and other symptoms. It occur within the first 24 hours after the initiation of any therapy for syphilis. Patients should be informed about this possible adverse reaction and how to manage it if it occurs. It occurs most frequently among persons who have early syphilis, presumably because bacterial burdens are higher during these stages. Antipyretics can be used to manage symptoms.The Jarisch-Herxheimer reaction might induce early labor or cause fetal distress in pregnant women, but this should not prevent or delay therapy
Management of Sex Partners
Sexual transmission of T. pallidum is thought to occur only when mucocutaneous syphilitic lesions are present. Such manifestations are uncommon after the first year of infection. In case you are exposed sexually to a person who has primary, secondary, or early latent syphilis you should tested and treated according to the following recommendations:
- Persons who have had sexual contact with a person who receives a diagnosis of any form of syphilis within 90 days preceding the diagnosis should be treated presumptively for early syphilis, even if serologic test results are negative.
- Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis >90 days before the diagnosis should be treated presumptively for early syphilis if serologic test results are not immediately available and the opportunity for follow-up is uncertain. If serologic tests are negative, no treatment is needed. If serologic tests are positive, treatment should be based on clinical and serologic evaluation and stage of syphilis.
- In some areas or populations with high rates of syphilis, health departments recommend notification and presumptive treatment of sex partners of persons with late latent syphilis who have high nontreponemal serologic test titers (i.e., >1:32), because high titers might be indicative of early syphilis. These partners should be managed as if the index case had early syphilis.
- Long-term sex partners of persons who have late latent syphilis should be evaluated clinically and serologically for syphilis and treated on the basis of the evaluation’s findings.
The following sex partners of persons with syphilis are considered at risk for infection and should be confidentially notified of the exposure and need for evaluation: partners who have had sexual contact within;
- 1) 3 months plus the duration of symptoms for persons who receive a diagnosis of primary syphilis,
- 2) 6 months plus duration of symptoms for those with secondary syphilis, and
- 3) 1 year for persons with early latent syphilis.
Primary and Secondary Syphilis
Parenteral penicillin G has been used effectively to achieve clinical resolution such as the healing of lesions and prevention of sexual transmission. It also prevent late sequelae.
Recommended Regimen for Adults
- Benzathine penicillin G 2.4 million units IM in a single dose
Recommended Regimen for Infants and Children
- Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose
Infants and children aged >1 month who receive a diagnosis of syphilis should have birth and maternal medical records reviewed to assess whether they have congenital or acquired syphilis .
Other Management Considerations
All people who have primary and secondary syphilis should be tested for HIV infection. In geographic areas in which the prevalence of HIV is high, persons who have primary or secondary syphilis should be retested for acute HIV in three months if the first HIV test result was negative.
Persons who have syphilis and symptoms or signs suggesting neurologic disease (e.g., cranial nerve dysfunction, meningitis, stroke, and hearing loss). Or ophthalmic disease (e.g., uveitis, iritis, neuroretinitis, and optic neuritis) should have an evaluation that includes CSF analysis, ocular slit-lamp ophthalmologic examination, and otologic examination. Treatment should be guided by the results of this evaluation.
Invasion of CSF by T. pallidum accompanied by CSF laboratory abnormalities is common among adults who have primary or secondary syphilis . In the absence of clinical neurologic findings, no evidence supports variation from the recommended treatment regimen for primary and secondary syphilis. Symptomatic neurosyphilis develops in only a limited number of persons after treatment with the penicillin regimens recommended for primary and secondary syphilis. Therefore, unless clinical signs or symptoms of neurologic or ophthalmic involvement are present, routine CSF analysis is not recommended for persons who have primary or secondary syphilis.
Clinical and Serological Evaluation
Your doctor may do clinical and serologic evaluation at 6 and 12 months after treatment. More frequent evaluation might be prudent if follow-up is uncertain or if repeat infection is a concern. You should compare serological response titer at time of treatment. However, assessing serologic response to treatment can be difficult to your doctor, and definitive criteria for cure or failure have not been well established. In addition, nontreponemal test titers might decline more slowly if previously treated for syphilis .
If you have signs or symptoms that persist or recur for more than 2 weeks. And with at least a fourfold increase in nontreponemal test titer persisting for >2 weeks you are likely to experience treatment failure or you are re-infected. You should be retreated and reevaluated for HIV infection. Because treatment failure your doctor can not reliably distinguished it from reinfection with T. pallidum,For this case a CSF analysis also should be performed. Treatment should be guided by CSF findings.
Failure of nontreponemal test titers to decline fourfold within 6–12 months after therapy for primary or secondary syphilis might be indicative of treatment failure. However, clinical trial data have demonstrated that 15%–20% of persons with primary and secondary syphilis treated with the recommended therapy will not achieve the fourfold decline in nontreponemal titer used to define response at 1 year after treatment . Serologic response to treatment appears to be associated with several factors, including the person’s stage of syphilis (earlier stages are more likely to decline fourfold and become negative). And initial nontreponemal antibody titers (lower titers are less likely to decline fourfold than higher titers) .
Optimal management of persons who have less than a fourfold decline in titers after treatment of syphilis is unclear. At a minimum, these persons should receive additional clinical and serologic follow-up and be evaluated for HIV infection. If additional follow-up cannot be ensured, retreatment is recommended. Because treatment failure might be the result of unrecognized CNS infection, CSF examination can be considered in such situations.
For retreatment, weekly injections of benzathine penicillin G 2.4 million units IM for 3 weeks is recommended; unless CSF examination indicates that neurosyphilis is present . Serologic titers might not decline despite a negative CSF examination and a repeated course of therapy . In these circumstances, although the need for additional therapy or repeated CSF examinations is unclear, it is not generally recommended.