Syphilis Flashcards
What bacterium causes syphilis?
Treponema pallidum
How does syphilis affect the risk of HIV transmission?
Increased risk of sexual acquisition and transmission
What are the common clinical manifestations of primary syphilis?
Single painless nodule that ulcerates to form a classic chancre
What can atypical presentations of primary syphilis include in people with HIV?
Multiple or atypical painful chancres; primary lesions may be absent
What are the typical symptoms of secondary syphilis?
Mucocutaneous lesions, generalized lymphadenopathy, fever, malaise, anorexia, arthralgias, headache
What is latent syphilis?
Serologic reactivity without clinical signs and symptoms
How is latent syphilis categorized?
Early latent (≤1 year), late latent (>1 year), unknown duration
What characterizes tertiary syphilis?
Gumma, cardiovascular syphilis, psychiatric manifestations, late neurosyphilis
What are common presentations of neurosyphilis?
Cranial nerve dysfunction, meningitis, stroke, changes in mental status
What ocular manifestations can occur in syphilis?
Syphilitic uveitis, neuroretinitis, optic neuritis
What diagnostic methods are definitive for early syphilis?
Darkfield microscopy and molecular tests to detect T. pallidum
What is the traditional algorithm for serologic diagnosis of syphilis?
Nontreponemal tests followed by treponemal tests for confirmation
What factors can cause false-positive nontreponemal test results?
HIV, autoimmune disease, vaccinations, injection drug use, pregnancy, older age
What does a reactive treponemal test indicate?
Lifetime reactivity regardless of treatment or disease activity
What is the reverse-sequence screening algorithm for syphilis?
Treponemal EIA or CIA as a screening test followed by a nontreponemal test if positive
What is the significance of CSF examination in diagnosing neurosyphilis?
Depends on a combination of CSF tests, reactive serologic results, and neurologic symptoms
What CSF abnormalities are common in early-stage syphilis?
Elevated protein and mononuclear pleocytosis
What is the clinical significance of CSF laboratory abnormalities in people without neurologic symptoms?
Unknown clinical significance
What should all people with ocular symptoms and reactive syphilis serology receive?
A full ocular examination
True or False: Nontreponemal test titers usually increase after treatment.
False
What is the recommended treatment for ocular syphilis?
Similar to neurosyphilis treatment
Fill in the blank: Primary or secondary syphilis may cause a transient decrease in _______ cell count.
CD4 T lymphocyte
What clinical manifestations may be more common in people with HIV and neurosyphilis?
Concomitant ocular syphilis or meningitis
What is the typical timeline for progression from primary to secondary syphilis?
2 to 8 weeks
What type of lesions can condylomata lata resemble?
Condylomata acuminata caused by human papillomavirus
What is the definition of early latent syphilis?
Serologic evidence of infection during the preceding year
What is the recommended action if serologic tests do not correspond with clinical findings?
Presumptive treatment and consideration of other tests
What tests are used to diagnose neurosyphilis?
CSF tests including CSF cell count, CSF protein, and CSF-VDRL
Diagnosis also considers reactive serologic test results and neurologic signs and symptoms.
What is the CSF leukocyte count cutoff that may improve specificity for diagnosing neurosyphilis in people with HIV?
> 20 WBC/mm3
What is considered diagnostic of neurosyphilis in individuals with neurologic signs or symptoms?
A reactive CSF-VDRL in a specimen not contaminated with blood
What should be considered even with a negative CSF-VDRL in people with neurologic signs or symptoms?
Neurosyphilis should be considered
What tests may be warranted in cases of suspected neurosyphilis with a negative CSF-VDRL?
FTA-ABS or TP-PA testing on CSF
Is the CSF FTA-ABS test more sensitive or specific than the CSF-VDRL for neurosyphilis?
Highly sensitive but less specific
What is the recommendation regarding RPR tests of the CSF?
They are associated with a high false-negative rate and are not recommended
What is the effectiveness of PCR-based diagnostic methods for neurosyphilis?
Not currently recommended as diagnostic tests
Who should be treated after exposure to Treponema pallidum?
Individuals exposed sexually within 90 days preceding diagnosis of primary, secondary, or early latent syphilis in a sex partner
What is the treatment recommendation for individuals exposed to syphilis >90 days before diagnosis?
Treat if serologic test results are not available immediately and follow-up is uncertain
What is the recommended frequency for serologic screening for syphilis in sexually active individuals with HIV?
At least annually, with more frequent screening every 3–6 months for those with multiple or anonymous partners
What should be done for individuals with recent sexual contact with a person with syphilis?
They should be evaluated clinically and serologically and treated presumptively
What is the post-exposure prophylaxis dose of doxycycline after unprotected anal sex?
200 mg
What did recent studies find about doxycycline post-exposure prophylaxis among MSM and transgender women?
It reduced incident syphilis by 73%
Why is azithromycin not recommended for secondary prevention of syphilis?
Due to treatment failures reported in people with HIV and associated chromosomal mutations
What is the recommended therapy for primary, secondary, and early latent syphilis?
Benzathine penicillin G 2.4 million units IM in a single dose
What is the alternative therapy for penicillin-allergic patients with early syphilis?
Doxycycline 100 mg PO twice daily for 14 days or Ceftriaxone 1 g IM or IV daily for 10–14 days
What is the recommended therapy for late latent syphilis?
Benzathine penicillin G 2.4 million units IM weekly for three doses
What is the recommended therapy for neurosyphilis?
Aqueous crystalline penicillin G 18–24 million units per day for 10–14 days
What should be done for patients with penicillin allergy and neurosyphilis?
Desensitization to penicillin is recommended
What is the Jarisch-Herxheimer reaction?
An acute febrile reaction that can occur within the first 24 hours after therapy
What should be informed to patients regarding the Jarisch-Herxheimer reaction?
It is not an allergic reaction to penicillin
What is the recommended treatment for early-stage syphilis in people with HIV?
Benzathine penicillin G is recommended (AII).
What is the alternative therapy for early-stage syphilis and its evaluation status?
Doxycycline, 100 mg orally twice daily for 28 days; however, it has not been sufficiently evaluated in people with HIV (BIII).
What is suggested by limited studies regarding ceftriaxone for syphilis treatment?
Ceftriaxone may be effective, but the optimal dose and duration of therapy have not been determined.
What should be done for people with HIV who have clinical evidence of tertiary syphilis?
They should have CSF examination to rule out CSF abnormalities before therapy is initiated.
What is the recommended treatment for late-stage syphilis if the CSF evaluation is normal?
Three weekly IM injections of 2.4 million units of benzathine penicillin G (AII).
What is the treatment regimen for people with HIV diagnosed with neurosyphilis?
IV aqueous crystalline penicillin G, 18 to 24 million units daily, or procaine penicillin, 2.4 million units IM once daily plus probenecid 500 mg orally four times a day for 10 to 14 days (AII).
Why should probenecid not be administered to people with HIV allergic to sulfa medications?
Due to potential allergic reaction; therefore, IV penicillin is recommended (AIII).
What is the Jarisch-Herxheimer reaction?
An acute febrile reaction that can occur within the first 24 hours after initiation of treatment for syphilis.
How should clinical and serologic responses be monitored after treatment of early-stage syphilis?
At 3, 6, 9, 12, and 24 months after therapy.
What indicates treatment failure in early-stage syphilis?
Persistent or recurring clinical signs or symptoms, or a sustained fourfold increase in serum nontreponemal titers.
What is the recommended management for people with persistent nontreponemal titers after treatment?
They should be managed as a possible treatment failure.
What is the significance of a fourfold decline in nontreponemal titers?
It is used to define treatment response.
What are the special considerations for screening syphilis during pregnancy?
Serologic screening should be conducted at the first prenatal visit and at 28 weeks.
What should be done if a treponemal test is positive during pregnancy?
All positive tests should be confirmed with a quantitative nontreponemal test (RPR or VDRL).
What is the risk of transmission to the fetus related to syphilis stages?
Rates of transmission are highest with primary, secondary, and early latent syphilis.
What is the recommended treatment for syphilis during pregnancy?
Benzathine penicillin G is recommended.
Fill in the blank: People with HIV who are on effective ART and show serologic responses after neurosyphilis treatment do not require _______.
repeated CSF examinations.
What is the role of benzathine penicillin G in managing syphilis in pregnancy?
It is the only known effective antimicrobial for preventing transmission to the fetus and for treatment of fetal infection.
What should be documented before a postpartum individual or neonate leaves the hospital?
Maternal syphilis serologic status determined at least once during pregnancy.
What should be done if both RPR and TP-PA remain negative during pregnancy?
No further treatment is necessary.
True or False: Treatment with ART needs to be delayed until treatment for syphilis has been completed.
False.
What factors can affect the serologic response to treatment in people without HIV?
- Younger age
- Earlier syphilis stage
- Higher RPR titer.
What is indicated by a decline in CSF lymphocytosis during neurosyphilis treatment?
It is the earliest CSF indicator of response to treatment.
What is the significance of serologic screening for syphilis during pregnancy?
It helps identify pregnant individuals at risk for adverse outcomes related to syphilis.
What should be considered if there is a sustained fourfold increase in nontreponemal titers?
Treatment failure or reinfection.
What might sustained low nontreponemal titers after treatment indicate?
They might not require additional treatment
Rising or persistently high antibody titers may indicate reinfection or treatment failure, warranting retreatment.
What is the recommended treatment for syphilis during pregnancy?
Benzathine penicillin G
It is the only known effective antimicrobial for preventing transmission to the fetus and treating fetal infection.
What is the suggested regimen for early syphilis management during pregnancy?
A second dose of benzathine penicillin G 2.4 million units IM 1 week after the initial dose
This may benefit congenital syphilis prevention.
When should a second dose of benzathine penicillin be administered?
No later than 9 days after the first dose
This is crucial for effective treatment.
What should be done for sexual partners of pregnant individuals with syphilis?
They should be referred for evaluation and treatment
This is essential to prevent further transmission.
What should be done for pregnant individuals with a history of penicillin allergy?
Desensitization and treatment with penicillin should be performed
No alternatives have proven effective and safe for preventing fetal infection.
Which antibiotics should not be used during pregnancy for syphilis treatment?
Erythromycin and azithromycin
These regimens do not reliably cure infection in the pregnant individual or the fetus.
What antibiotics should be avoided in the second and third trimesters of pregnancy?
Tetracyclines
They can have adverse effects on the developing fetus.
What may occur if syphilis is treated during the second half of pregnancy?
It may precipitate preterm labor or fetal distress
This can happen if a Jarisch-Herxheimer reaction occurs.
What should be monitored after treatment for syphilis in the second half of pregnancy?
Fetal and contraction monitoring for 24 hours
This is recommended if sonographic findings indicate fetal infection.
When should maternal serologic titers be repeated after treatment for syphilis diagnosed before 24 weeks’ gestation?
Not before 8 weeks after treatment, then again at delivery
This timing is important for assessing treatment response.
What indicates inadequate antenatal treatment for syphilis?
Delivery within 30 days of therapy with clinical signs of infection present
Also, if maternal nontreponemal titer at delivery is fourfold higher than the pre-treatment titer.
Is there evidence that pregnant women with syphilis and HIV are at increased risk for delayed treatment response?
No
There is no evidence of increased risk compared to women without HIV.
