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Chapter 143: Syphilis

Roy Chan; Martin Chio; Benson Yeo

SYPHILIS

Syphilis is a sexually transmitted infection caused by Treponema pallidum. With the exception of mother-to-child transmission, syphilis is almost exclusively spread by direct contact with infectious lesions. See Table 143-1.

Table 143-1Syphilis—Clinical and Serological Features
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Table 143-1 Syphilis—Clinical and Serological Features
STAGE OF SYPHILIS CLINICAL FEATURES NON-TREPONEMAL (NT) TESTS RPR/VDRL SPECIFIC (TREPONEMAL) TESTS EIA/TPHA/TPPA/LIA
Primary

Chancre

Regional lymphadenopathy

+/−

(rising)

 +/−
Secondary

Papulosquamous rash

Condylomata lata

Regional/generalized lymphadenopathy

Alopecia

Mucosal snail-track ulcers

+

(high)

 +
Early and late latent Absent

+/−

(low or zero)

 +
Tertiary (except neurosyphilis) Benign tertiary/gummatous disease (usually skin and subcutaneous tissues) or Cardiovascular disease (aortitis, aortic aneurysm, aortic regurgitation) + +
Neurosyphilis May be asymptomatic or symptomatic—atypical neurosyphilis (eg, ocular syphilis, otosyphilis), meningovascular, tabes dorsalis, and general paresis.

+

Diagnosis depends on CSF tests in the presence of reactive serologic test results and neurologic signs and symptomse

 +
Syphilis in HIV co-infected patients

Clinical manifestations are similar regardless of HIV serostatus.

Perform thorough neurologic, ocular, and otic examination.

 Interpretation of serologic tests is the same as for persons without HIV.  
Syphilis during pregnancy Clinical manifestations of each stage of syphilis are not affected by pregnancy Interpretation of serologic tests is not affected by pregnancy. All pregnant women should be screened serologically at first antenatal visit.
Congenital

Early Congenital

Vesicobullous eruption, copper-coloured palmoplantar rash, perinasal/oral papules

 

 

Late congenital

Ocular issues

- Interstitial keratitis

Pegshaped teeth

Photosensitivity

Bone pain

+

(rising)

NT titer 4× higher than mothers.

Perform CSF examination, long bone x-rays, other tests as indicated

+ (low)

+

 

 

 

+

Therapeutic Approach

The aim of treating early or infectious syphilis is to cure the infection, and to break the chain of transmission. The aim of treating noninfectious syphilis is to cure the infection and to halt progress of organ damage. Parenteral penicillin G is the drug of choice, the preparation used (ie, benzathine, aqueous procaine, or aqueous crystalline), dosage, and length of treatment depend on the stage and clinical manifestations of the disease. Patients also need to be screened for other STI/HIV, and sexual contacts of infectious syphilis need to be traced and tested. See Table 143-2.

Table 143-2Syphilis Treatment Table
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Table 143-2 Syphilis Treatment Table
STAGE OF SYPHILIS FOLLOW-UP/MONITORING LEVEL OF EVIDENCE FOR TREATMENT
Primary

First-line treatment.

Penicillin is the drug of choicea

Second-line treatment

IM benzathine penicillin 2.4 MU × 1

PO doxycycline 100 mg twice daily for 14 d

Ceftriaxone (1 g daily either IM or IV for 10 d)

Clinical review of resolution of lesions.

NT serologic tests should be repeated at 6, 12, and 24 mob

Screening for HIV and other STI.

Offer HIV PrEP.

Partner management.

IB1-5

IC2-4,6,7
Secondary...

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