Syphilis - Acute
Rahul Soman, M. Pharm
Definition
A sexually transmitted disease cause by the spirochete Treponema pallidum
Medical History
* Substance Abuse
* Imprisonment
* Prostitution
* Sexual intercourse
Findings
* Abdominal pain - Acute
* Abnormal vision
* Argyll-Robertson pupil
* Arthralgia
* Bone pain
* Chancroid - anogenital ulcer
* Chancroid - Acute
* Condyloma latum
* Female genital ulcers
* Fever
* Genital ulcer
* Headache
* Hematochezia
* Hepatosplenomegaly
* Loss of appetite
* Lymphadenopathy - Acute
* Malaise
* Myalgia
* Nuchal rigidity
* Pain in throat
* Pain of eye structure
* Personality change
* Pruritus of skin
* Rash - Acute
* Rectal pain
* Secondary syphilis of mucous membrane
* Secondary syphilis of tonsil
* Seizure
* Sensorineural hearing loss, bilateral
* Syphilitic chancre of face
* Syphilitic chancre of oral mucous membranes
* Vomiting
* Weight loss
Tests
Screening, diagnosis, and therapy response in patients with known or suspected syphilis
* VDRL titer measurement, Serum: A four-fold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .
Suspected and known syphilis .
* Rapid plasma reagin test: A fourfold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .
Suspected or known congenital syphilis .
* Rapid plasma reagin test: A fourfold or greater rise in antibody titer is presumptive of syphilis but requires confirmatory treponemal testing .
Suspected syphilis
* Fluorescent treponemal antibody absorption test: A positive nontreponemal test followed by a positive FTA-ABS is suggestive of syphilis .
Suspected congenital syphilis
* Fluorescent treponemal antibody absorption test: For infants born to syphilitic mothers, a positive fluorescent treponemal antibody absorption (FTA-ABS) test confirming a reactive nontreponemal test is suggestive of congenital syphilis .
Suspected syphilis
* Microhemagglutination test for antibody to syphilis: A positive nontreponemal test followed by a positive microhemagglutination test is suggestive of syphilis .
Suspected syphilis
* Dark field microscopy: Identification of Treponema pallidum by darkfield microscopy can confirm the diagnosis of early syphilis and congenital syphilis (in neonates) .
Suspected syphilis
* Direct fluorescent antibody test for syphilis: Detection of the presence of T pallidum by direct fluorescent antibody microscopy is considered diagnostic for early and congenital syphilis .
Suspected HIV infection
* HIV-1 and HIV-2 antibody, single assay: The first time a person is found to be seropositive, the initial reactive (positive) result must prompt a repeat screening test.
Suspected and known neurosyphilis and patients with a high risk of developing neurosyphilis
* Cerebrospinal fluid examination: The cerebrospinal fluid reflects both the presence of the neurosyphilitic process and disease activity.
Monitoring disease activity in neurosyphilis
* White blood cell count, automated, cerebrospinal fluid: A cerebrospinal fluid cell count greater than 5/mm3 and specific serology findings for Treponema pallidum may be diagnostic of active neurosyphilis .
Suspected neurosyphilis
* Cerebrospinal fluid protein: An elevated cerebrospinal fluid (CSF) protein level may suggest neurosyphilis in the presence of other criteria .
Suspected neurosyphilis in the presence of a positive serum treponemal test, and known neurosyphilis to monitor therapy response
* VDRL titer measurement, Cerebrospinal fluid: A positive VDRL-CSF is considered diagnostic for neurosyphilis in the absence of sample contamination .
Suspected neurosyphilis
* Fluorescent treponemal antibody absorption test, Cerebrospinal fluid: A negative cerebrospinal fluid fluorescent treponemal antibody absorption test may rule out a diagnosis of neurosyphilis .
Suspected meningovascular syphilis in the tertiary stage
* CT of head: Head CT findings in patients with meningovascular syphilis suggest vasculitis and consist of small infarcts affecting both the gray and white matter .
Detection of bone lesions in patients with suspected secondary or tertiary (late) syphilis
* Radioisotope scan of bone: In tertiary syphilis, periostitis is shown as increased cortical activity, osteomyelitis as focal hot spots, and gummas as photopenic or "cold" defects
Differential Diagnosis
* Primary syphilis
* Chancroid - Acute
* Secondary syphilis
* Genital herpes simplex
* Latent syphilis with positive serology
* Cardiovascular syphilis
* Congenital syphilis
* Granuloma inguinale
* HIV infection
* Fixed drug eruption
* Latent early syphilis
* Late syphilis
* Neurosyphilis
* Syphilitic retrobulbar neuritis
* Meningovascular syphilis - quaternary stage
* Lymphogranuloma venereum
* Secondary syphilitic uveitis
* Optic neuritis
* Syphilitic meningitis
* Tabes dorsalis
* Condyloma acuminatum
* Infectious mononucleosis - Acute
* Late latent syphilis
* Secondary syphilis of liver
* Secondary syphilitic periostitis
* Asymptomatic neurosyphilis
* Latent syphilis unspecified
* Syphilitic bursitis
* General paresis - neurosyphilis
* Jarisch Herxheimer reaction
* Gastric syphilis
Treatment
Drug Therapy
Suspected and known primary or secondary syphilis
PENICILLIN G BENZATHINE
Adults: 2.4 million units IM in a single dose
Pediatrics: 50,000 units/kg (maximum 2.4 million units) IM in a single dose
Suspected and known early latent syphilis
PENICILLIN G BENZATHINE
Adults: 2.4 million units IM in a single dose
Pediatrics: 50,000 units/kg IM (maximum 2.4 million units) IM in a single dose
Suspected and known late latent syphilis or latent syphilis of unknown duration
PENICILLIN G BENZATHINE
Adults: 2.4 million IM once weekly for 3 weeks for a total of 7.2 million units
Pediatrics: 50,000 units/kg (maximum 2.4 million units) IM once weekly for 3 weeks for a total of 150,000 units/kg (total maximum 7.2 million units)
Suspected and known tertiary syphilis in the absence of neurosyphilis
PENICILLIN G BENZATHINE
Adults: 2.4 million IM once weekly for 3 weeks for a total of 7.2 million units
Suspected and known neurosyphilis
PENICILLIN G POTASSIUM
Adults: 18 to 24 million units/day, administered as 3 to 4 million units IV every 4 hours or continuous infusion, for 10 to 14 days
PENICILLIN G PROCAINE - PROBENECID (Related toxicological information in PROBENECID)
Adults: Procaine penicillin 2.4 million units IM once daily AND probenecid 500 mg orally 4 times daily, both for 10 to 14 days
Suspected and known congenital syphilis in children older than 1 month of age
PENICILLIN G POTASSIUM
Pediatrics (>1 month): 200,000 to 300,000 units/kg/day IV, administered as 50,000 units/kg every 4 to 6 hours for 10 days
Suspected and known congenital syphilis in neonates
PENICILLIN G POTASSIUM
Neonates: 100,000 to 150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter, for a total of 10 days. If more than 1 day of therapy is missed, restart the entire regimen
PENICILLIN G PROCAINE
Neonates: 50,000 units/kg/dose IM in a single daily dose for 10 days. If more than 1 day of therapy is missed, restart the entire regimen
Procedural Therapy
Reportable infectious diseases
* Infectious disease notification: In the United States, specific infectious diseases must be reported to the state or local public health department .
Sexual contacts of patients with a sexually transmitted disease
* Sexual partner notification: Patients with certain sexually transmitted diseases need to refer their partners for evaluation and treatment .
At risk for sexually transmitted disease
* Infection prevention education: Patient education and counseling is one of the essential strategies for the prevention and control of sexually transmitted diseases (STDs) .
Non-Procedural Therapy
Syphilis
* Patient Education
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