Syphilis Flashcards
May 2020:
There is currently a syphilis epidemic in Auckland.
Syphilis is a notifiable disease
Syphilis can be complex to manage
- All +ve serology, suspected cases and syphilis contacts should be discussed with, or referred to, a sexual health specialist.
About syphilis
Syphilis is a serious bacterial infection due to the bacterium Treponema pallidum
can cause significant complications if undiagnosed and untreated.
Most people with syphilis in NZ are thought to have become infected inside NZ.
Syphilis is spread by intimate contact with muco-cutaneous skin so is transmitted through sex, including oral sex.
Condoms are not fully protective.
can be transmitted to the fetus or neonate if a pregnant woman is infected, resulting in serious perinatal morbidity and mortality.
There has been a large increase in syphilis cases in the Auckland region since 2014.
Mainly being diagnosed in MSM but about 20% of cases have been diagnosed in heterosexuals.
Syphilis has 3 clinical stages:
primary
secondary
tertiary syphilis
Syphilis can also be latent without any s/s (50% ) and will only be diagnosed by serological testing.
Latent syphilis is divided into:
- early latent syphilis (
- late latent syphilis (beyond 2 years).
Primary syphilis symptoms
Solitary painless genital, anal, or mouth ulcer (chancre) which spontaneously resolves.
The ulcer may be painful.
Occasionally there are multiple lesions that are indistinguishable from genital herpes.
Incubation is 10 - 90 days after infection with an average of 3 weeks.
Secondary syphilis symptoms
A generalised non-pruritic body rash that may resemble pityriasis rosea or a drug reaction.
- Any rash affecting the palms of hands or soles of feet.
- usually appears 2–4 m after the primary chancre (or even longer)
Atypical mouth ulcers.
Patchy alopecia.
Unexplained liver enzyme abnormalities.
Unexplained persistent lymphadenopathy.
Pyrexia of unknown origin.
Unexplained neurological symptoms including;
- meningitis
- stroke syndromes
- cranial nerve palsies, including sensori-neural deafness.
The usual incubation period is 2 to 6 months with an average of 6 weeks.
What is Early latent syphilis
Early latent is defined as less than 2 years duration, and late latent beyond 2 years.
It includes currently asymptomatic people who have a history of symptoms consistent with primary or secondary syphilis within the last 2 years.
Latent syphilis symptoms
This means syphilis with no clinical symptoms or signs.
Some people never develop symptoms and will only be diagnosed by serological tests.
If untreated all people become asymptomatic over a period of 12 to 24 m after initial infection.
After 24 m people are no longer infectious to sexual contacts but women may still pass the infection on to the unborn foetus
Sexual history
Frame the discussion with “We ask everyone the same questions, they may seem intrusive but I’m just trying to find out risks and what tests you may need.”
Do you have any problems or symptoms that you are concerned about?
Are your sexual partners or contacts male, female, or both?
When was the last time you had sex?
Was this with a regular or short-term sexual partner or contact?
If regular partner, when was the last time you had sex with someone other than your regular partner?
With short-term contacts, do you use condoms always, sometimes, never?
How many partners or contacts have you had:
- in the last 3 months?
- in the last 12 months?
Do sexual encounters include vaginal, oral, or anal sex?
Have you previously been diagnosed with a STI?
Have any of your sexual contacts had a STI? If so, what was it?
Has anyone forced you to have sexual encounters against your wishes?
Examine the patient. Check for:
Ggenital lesions – can be multiple, and indistinguishable from genital herpes.
Lymphadenopathy –
- enlarged, rubbery
- non tender regional nodes in primary syphilis (associated with chancre)
- more generalised in secondary syphilis.
Rash
Mouth ulcers.
Serology
reagin tests, treponemal test, PCR
- Arrange syphilis serology for:
- anyone presenting with possible symptoms or signs of infectious syphilis.
- If painless genital ulcer(s) with or without inguinal lymphadenopathy, also take a flocked (red top) viral swab for herpes simplex virus (HSV), which is still the most common cause of genital ulceration. Rub base of lesions firmly to maximise yield.
- MSM – conduct syphilis serology at least annually but more frequently in men who have multiple sexual contacts or are symptomatic.
- sexual contacts of anyone diagnosed with syphilis – sexual contacts may still be infected despite initial negative syphilis serology, as serology can take up to 3 months to become positive.
- all people requesting screening for sexually transmitted infections.
- all pregnant women as part of their first antenatal screen.
- repeat in women who change partner during pregnancy or who are symptomatic.
- Offer comprehensive STI testing to anyone at increased risk of STI
- Review serology:
- Asymptomatic people may have positive serology.
- Syphilis serology can take up to 3 months to become positive after exposure.
Assessment of risk
Risk is increased if within the last year, pt has had:
≥ 2 sexual partners
a new sexual partner in the last 3 months
an STI
a sexual partner with an STI.
TEST IF
MSM (at least annually, but ideally with every sexual health check)
HIV positive (at least annually, but ideally with every sexual health check)
Routine antenatal screen; consider rescreening in later pregnancy if partner change
Routine immigration screen
A sexual contact of a person with syphilis
Routine sexual health check
Interpretation of serology results, General points
Syphilis serology can be difficult to interpret, therefore should be discussed with a sexual health specialist if +ve.
It can take up to 90 days for a test to become +ve after infection, therefore contacts of infectious syphilis should be treated empirically regardless of test results.
Some serological tests remain reactive for life even after successful treatment.
F/U testing to monitor non-treponemal test titres (RPR/VDRL) is important to establish effective cure.
recommended testing interval
Arrange an early test at about 4 weeks post-risk.
If the result is -ve, do another syphilis serology test at 3 m post-risk before reassuring pt that they are not infected.
If pt is a contact of an index case of syphilis and last sexual contact with that person was less than 3 m ago, testing and empirical Rx is recommended.
Other recommended tests
HIV serology
Routine STI tests (see Sexual Health Check guideline www.nzshs.org/guidelines)
In MSM also request hepatitis A and B serology, unless known to be immune
In persons with a history of IDU, incarceration, or who use recreational drugs during sex, request hepatitis C serolog
Management
- Seek sexual health advice for all suspected and confirmed cases of syphilis.
- If pt has syphilis and is pregnant, request acute sexual health assessment and mark your request as urgent, must be managed by the sexual health service.
- Advise pt to refrain from any sexual activity until assessed or discussed with a specialist service.
- Do not prescribe any topical agents or oral antibiotics.
- Advise pt that the Auckland Sexual Health Regional Service will do contact tracing when they are referred.
- Notify the Medical Officer of Health by completing syphilis notification.
- If pt will be treated in the community:
- only be considered if GP is experienced with syphilis
- Seek sexual health advice first.
- Follow NZSHS guidelines for syphilis.
- For assistance with contact tracing, email stscontacttracing@adhb.govt.nz.
Recommended anti-microbial therapy
Early syphilis (primary, secondary or latent) of not > 2 yrs duration:
- benzathine penicillin 1.8 g IM as a single dose or
- procaine penicillin 1 g IM daily for 10 d
- For pts hypersensitive to penicillin: doxycycline 100 mg (o) 12 hrly for 14 d or
Late syphilis: more than 2 yrs or indeterminate duration:
- benzathine penicillin 1.8 g IM once wkly for 3 doses
Syphilis notification
Check the Ministry of Health case definitions for infectious and congenital syphilis.
Find appropriate form for congenital syphilis or for infectious syphilis at the ESR STI surveillance page.
https://surv.esr.cri.nz/public_health_surveillance/sti_surveillance.php
Complete pdf or Word form.
Send to ESR at the address or fax number on the forms.
There is a separate process for specialist sexual health clinics.
FOLLOW-UP
Infectious syphilis:
- Repeat serology at 3, 6 and 12 m
- Serological cure is defined by consistent four-fold (2 dilutions) drop in RPR titre
- Failure of RPR titre to decrease fourfold (2 dilutions) within 12 m indicates treatment failure – re-evaluation is necessary
- A subsequent four-fold (2 dilution) rise in RPR titre is an indication of re-infection – re-evaluation is necessary
Late latent syphilis and tertiary syphilis (excluding neurosyphilis):
- Repeat serology at 6 and 12 m to ensure remains serofast
- Fourfold (2 dilutions) increase in titre indicates either Rx failure or re-infection – re-evaluation is necessary
Tertiary syphilis symptoms
Late symptoms/complications may develop months or years later in about 1/3 of cases if not treated.
Complications include:
- skin lesions (gummas)
- cardiovascular
- neurological disease.
Management of sexual contacts
Referral or discussion with a sexual health specialist
Perform a full sexual health check.
Serology for syphilis and HIV.
Treat empirically for syphilis if sexual contact with infectious syphilis was < 3 m ago.
Advise to abstain from sexual activity until assessed or discussed with a specialist service.
Review in person in one week to discuss results and check resolution of any symptoms.
If they test +ve for syphilis – partner notification as above
