Going Off-Script: Dilemmas in the Evaluation and Treatment of Syphilis in Four Patients
Abstract
:1. Introduction
1.1. Syphilis Stages and Symptoms
1.2. Syphilis Diagnosis and Treatment
2. Detailed Case Presentations
2.1. Case 1: 39-Year-Old Male with Weight Gain and Edema
2.2. Case 2: 23-Year-Old Male with Genital Rash
2.3. Case 3: 22-Year-Old Male with Syphilis-Positive Sexual Partner
2.4. Case 4: 24-Year-Old Female with History of Syphilis
3. Discussion
Teaching Points for Diagnosis and Treatment
- As with other bacteria, previous infection with syphilis does not prevent future infections. Although treponemal antibodies can remain long after infection, NTT titers should decrease by four-fold in the 1–24 months following successful treatment [22,31]. Conversely, a four-fold increase in titer (i.e., two dilutions) likely indicates reinfection requiring further treatment [22].
- Latex condoms only protect as much skin as they cover. A patient who, within the previous three months, has had sexual contact with someone confirmed to have primary, secondary, or early latent syphilis should receive treatment regardless of their own test result or reported condom use [30].
- Effective social history taking can help to stratify a patient’s risk of a syphilis infection. Risk factors include engaging in MSM sexual behavior, taking HIV pre-exposure prophylaxis (PrEP), being HIV+, and having sexual contact with a partner who has tested positive for syphilis [32]. Other groups at risk include pregnant women, men under the age of 29, and individuals engaged in transactional sex [27]. However, the lack of these risk factors does not rule out syphilis infection. When faced with a constellation of nonspecific symptoms, providers should have a wide differential that includes syphilis.
- Although the traditional testing algorithm of first using a non-specific screening test (e.g., RPR, VDRL) followed by a confirmatory test (e.g., TP-PA, FTA-ABS) is still widely used, automated treponema-specific immunoassays are becoming more popular as an initial screen, followed by non-treponemal and different treponemal testing, if necessary [8]. PCR testing is also available in some locations.
- Penicillin remains the mainstay of treatment for syphilis across stages, populations, and age groups. Patients with a penicillin allergy should undergo desensitization. This is especially true in pregnant patients. If desensitization is contraindicated, other antibiotics may be acceptable for certain disease stages (e.g., doxycycline for primary and secondary syphilis), assuming close post-treatment monitoring can be assured [24].
- Latent syphilis is diagnosed if the patient tests positive without symptoms of primary, secondary, or tertiary disease. Early latent syphilis, defined by the CDC as seroconversion (or having exposure) within the last year, can be treated with one IM dose of penicillin G benzathine. However, late latent syphilis and latent syphilis of unknown duration require three weekly IM doses of penicillin G benzathine.
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
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Silverberg, B.; Sethman, C.; Williamson, J.; Craft, M.; Sharon, M.; Ashcraft, A.M. Going Off-Script: Dilemmas in the Evaluation and Treatment of Syphilis in Four Patients. Venereology 2023, 2, 124-131. https://doi.org/10.3390/venereology2030011
Silverberg B, Sethman C, Williamson J, Craft M, Sharon M, Ashcraft AM. Going Off-Script: Dilemmas in the Evaluation and Treatment of Syphilis in Four Patients. Venereology. 2023; 2(3):124-131. https://doi.org/10.3390/venereology2030011
Chicago/Turabian StyleSilverberg, Benjamin, Chad Sethman, Jonathan Williamson, Mary Craft, Melinda Sharon, and Amie M. Ashcraft. 2023. "Going Off-Script: Dilemmas in the Evaluation and Treatment of Syphilis in Four Patients" Venereology 2, no. 3: 124-131. https://doi.org/10.3390/venereology2030011