Syphilis and complications

Question 1

Jarisch Herxheimer reaction

Answer 1

acute febrile illness attributed to the release of Treponema pallidium components into the blood with organism death. Seen a few hours after treatment begins.

Question 2

acute onset fever, myaglias and rash progression within 24 hrs of secondary syphilis treatment with penicillin G

Answer 2

Jarisch-Herxheimer reaction presentation. Note the rash is the same one seen in secondary syphilis.

Question 3

When does Jarisch Herxheimer reaction start?

Answer 3

6-48 hrs post treatment initiation and seen commonly after primary or secondary syphilis. Can be seen in lyme and leptospirosis treatment oo

Question 4

What other illness can cause Jarisch Herxheimer reaction?

Answer 4

lyme disease and leptospirosis syphilis

Question 5

Treatment of Jarisch Herxheimer

Answer 5

IVF tylenol, NSAIDS self limiting within 48 hrs of onset.

Question 6

When do we use doxycycline to treat Syphilis?

Answer 6

in some cases of severe penicillin allergy.

Question 7

painless wartlike lesions seen in secondary syphilis

Answer 7

condyloma latum

Question 8

symptoms of secondary syphilis

Answer 8

can have systemic symptoms of: fever, malaise, headache, anorexia, diffuse LAD,

maculopapular rash (trunk, extremities and hands and soles and palms) condyloma latum

generalized LAD (enlarged epitrochlear nodes are seen a lot)

moth eaten alopecia

diffuse organ involvement - hepatitis, uveitis, and meningitis

Question 9

serological testing for secondary syphilis and diagnosis of syphilis

Answer 9

Almost always positive. Diagnose via VDRL or rapid plasma reagin test and confirmed via a treponemal specific test (FTA-ABS)

Question 10

how do we know that treatment was successful

Answer 10

repeat RPR testing should show a 4-fold fall within 6 to 12 months of treatment

there should be resolution of symptoms!

Question 11

What if repeat non treponemal serological testing 6 months after treatment is 1:8 from previous 1:256 and patient who had syphilis has had improvement in her symptoms?

Answer 11

• could mean inadequate or inappropriate treatment (failure to fall 4-fold within 6 to 12 months of treatment
• reinfection with new sex partner
• serofast reaction

Reason why observation and repeat RPR in another 6 months (because pt could just have low level titers for rest of life) is that pt no longer has symptoms of syphilis. Lack of four fold drop points to serofast reaction so should consider checking for HIV and VRDL

If there are persistent symptoms then consider treatment failure and need to get LP to rule out neurosyphilis.

Question 12

Low serofast titer of RPR after treatment

Answer 12

could mean it remains low level positive indefinitely after an initial 4 fold decline. needs repeat RPR in 6 months to make sure that titer is stable and not rising.

Question 13

IM penicillin is used to treat:

Answer 13

primary, secondary and latent syphilis.

if allergic to penicillin can use doxycycline for primary and secondary.

Question 14

if pt has positive nontreponemal test after syphilis tx and concerned for inadequate tx what test to order?

Answer 14

get LP to check for neurosyphilis and may need re treatment

Question 15

if pt has positive nontreponemal test after syphilis tx and concerned for reinfection what to do next?

Answer 15

ask if pt has a new sexual partner, new symptoms of primary or secondary syphilis

Need to retreat based on stage

Question 16

which antibodies are positive for life after syphilis treatment

Answer 16

treponemal pallidum particle agglutination or TP-PA

Question 17

what treponemal test to order on CSF if concerned for syphilis?

Answer 17

Order VRDL on CSF fluid to rule out neurosyphilis.

Question 18

positive nontreponemal testing after syphilis tx chart

Answer 18

Question 19

Tx for primary syphilis (chancre)

Answer 19

Penicillin G (IM) x 1 dose OR doxycycline 14 days

Question 20

Tx for secondary syphilis (diffuse rash)

Answer 20

Penicillin G (IM) x 1 dose OR doxycyline 14 days

Question 21

Tx for latent (asymptomatic) syphilis - early and late latent

Answer 21

Penicillin G (IM) x 3 doses, OR doxycycline x 28 days

Latent TB can be divided into early latent (<1 year) and late latent (>1 year or unknown duration).

Early latent: single dose benzathine penicillin G X1

Late latent: benzathine penicillin G IM weekly for 3 weeks.

Question 22

Tx for tertiary syphilis (Cardiovascular syphilis, gummas)

Answer 22

Aqueous Penicillin G (IM) q4h X 14 days

or ceftriaxone 14 days

Question 23

When can we get false positive RPR?

Answer 23

SLE (elevated ANA tier)

Question 24

Best test for chancre

Answer 24

check dark field microscopy. Checking RPR too soon won’t have enough time for body to make antibodies so can miss it

Question 25

When to order CSF analysis?

Answer 25

neurological or ophthalmological symptoms or any evidence of tertiary syphilis in other areas or has HIV infection.

Question 26

Latent syphilis is defined as:

early

late

Tx for each

Answer 26

latent syphilis is: asymptomatic pts with late syphilis or s_yphilis of unknown duration >1 yr_

actually can be divided into early latent and late latent.

Early latent: single dose benzathine penicillin G X1

Late latent: bnezathine penicillin G IM weekly for 3 weeks.

Question 27

Screening for Syphilis

Answer 27

RPR or syphilis antibody remain positive for life

Question 28

Confirmatory testing if screening test is positive?

Answer 28

treponema pallidum enzyme immunoassay

Question 29

how to know if reoccurrence or reinfection?

Answer 29

titers increase

Question 30

Summary chart of treatment of syphilis

Answer 30

If pt had anaphylactic response to pencillin would still try to desensitize them and treat with penicillin.

Question 31

Criteria for treatment for post exposure to syphilis

how does syphilis spread?

Answer 31

anyone who was exposed within 90 days prior to diagnosis with primary secondary, or early latent syphilis in a sex partner should get presumptive treatment even if pt is seronegative for syphilis

syphilis spreads by direct contact with infected lesions on genitalia, lips, oral cavity or breasts. Generally spread during 1st year of infection but can spread at any stage of syphilis.

Question 32

what is the correct order of testing for syphilis antibodies?

Answer 32

nontreponemal tests: rapid plasma reagin RPR) be ordered first

Treponemal tests (treponema pallidum enzyme assay) be used for confirmation but labs have switched this due to cost reasons.

If acute infection with chancre can get darkfield microscopy to diagnose because serology won’t have turned positive yet.

Question 33

in pts who are allergic to penicillin and need treatment for primary syphilis what to give instead?

Answer 33

doxycycline is preferred as alternate over azithromycin given increasing resistance in many areas.

Question 34

positive nontremponemal testing after syphilis treatment

Answer 34

positive nontremponemal testing after syphilis treatment

Question 35

Name the post exposure prophylaxis to syphilis?

Answer 35

Single dose benzathine pencillin IM (same for primary, secondary and early latent syphilis)

Question 36

tabes dorsalis is

Answer 36

tertiary syphilis and years after infection where the syphilis affects the posterior columns of the spinal cord

presents as sensory ataxia with l_ancinating pains that go upward._ see absent lower extremity reflexes and impaired vibratory and position sensation.

See Argyll Robertson pupil.

Question 37

presents as sensory ataxia with lancinating pains that go upward. see absent lower extremity reflexes and impaired vibratory and position sensation.

Answer 37

Tabes dorsalis or tertiary syphilis.

Question 38

ascending aorta dilation with aortic insufficiency and left heart failure.

Also has ascending aortic arch calficiation on CXR (not related to atherosclerosis)

Answer 38

cardiovascular syphilis. Seen years after infection.

Can be seen with tabes dorsalis.

Question 39

Treatment of tertiary syphilis:

Treatment of neurosyphilis:

Answer 39

WITHOUT neurosyphilis, tx for tertiary syphilis is IM penicillin weekly for 3 weeks.

IV aqueous penicillin for 10-14 day q4h for neurosyphilis:

Other forms of tertiary syphilis are: neurosyphilis, tabes dorsalis, cardiovascular syphilis

Question 40

Treatment of congenital syphilis is

Answer 40

aqueous penicillin G 50K unit/kg/dose IV every 8-12 hrs for 10 days

Question 41

heavy metal poisoning presentation

(on differential for tabes dorsalis because of presentation with impaired vibratory and position sense and absent lower extremity reflexes)

Answer 41

psychiatric abnormalities like irritability and neuropathies like wrist or foot drop.

Question 42

Best test for tabes dorsalis or cardiovascular syphilis?

Answer 42

treponemal assays – remain 100% sensitive.

Question 43

chancre is

Answer 43

primary syphilis and develops at inoculation site. This happens on external genitalia and at posterior pharynx, anus or vagina. See 1-2 cm lesions (teeming with treponemal spirocytes )

painless and non exudative base with indurated margin. See bilateral LAD (cervical)

Question 44

early neurosyphilis is

Answer 44

CSF invasion and can caue CSF lab abnormalities without clinical symptoms.

can have positive VRDL, lymphocytic pleocytosis and elevated protein. CSF VDRL can be negative in 70% of pts, negative test doesn’t rule out syphilis

Treatment: IV aqueous penicillin G for 10-14 days. With pencillin allergey need to get skin testing and desensitization

Question 45

how to follow someone with neurosyphilis after treatment?

Answer 45

need serial CSF analysis every 3-6 months after treatment and every 6 months until CSF shows normal WBC and negative VDRL.

If they no negative VDRL after 2 years need to get retreatment

Question 46

Treatment of primary and secondary syphilis if allergic to penicillin

Answer 46

doxycycline.

Question 47

If someone fails to improve when treated for syphilis next thing to do is:

Answer 47

failure of nontreponemal test titers decline fourfold within 6 months RPR : 1:32 to 1:8 after primary or secondary syphilis

Ned to check lumbar puncture, and check HIV