Syphilis and complications Flashcards
Jarisch Herxheimer reaction
acute febrile illness attributed to the release of Treponema pallidium components into the blood with organism death. Seen a few hours after treatment begins.
acute onset fever, myaglias and rash progression within 24 hrs of secondary syphilis treatment with penicillin G
Jarisch-Herxheimer reaction presentation. Note the rash is the same one seen in secondary syphilis.
When does Jarisch Herxheimer reaction start?
6-48 hrs post treatment initiation and seen commonly after primary or secondary syphilis. Can be seen in lyme and leptospirosis treatment oo
What other illness can cause Jarisch Herxheimer reaction?
lyme disease and leptospirosis syphilis
Treatment of Jarisch Herxheimer
IVF tylenol, NSAIDS self limiting within 48 hrs of onset.
When do we use doxycycline to treat Syphilis?
in some cases of severe penicillin allergy.
painless wartlike lesions seen in secondary syphilis
condyloma latum
symptoms of secondary syphilis
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
serological testing for secondary syphilis and diagnosis of syphilis
Almost always positive. Diagnose via VDRL or rapid plasma reagin test and confirmed via a treponemal specific test (FTA-ABS)
how do we know that treatment was successful
repeat RPR testing should show a 4-fold fall within 6 to 12 months of treatment
there should be resolution of symptoms!
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?
- 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.
Low serofast titer of RPR after treatment
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.
IM penicillin is used to treat:
primary, secondary and latent syphilis.
if allergic to penicillin can use doxycycline for primary and secondary.
if pt has positive nontreponemal test after syphilis tx and concerned for inadequate tx what test to order?
get LP to check for neurosyphilis and may need re treatment
if pt has positive nontreponemal test after syphilis tx and concerned for reinfection what to do next?
ask if pt has a new sexual partner, new symptoms of primary or secondary syphilis
Need to retreat based on stage
which antibodies are positive for life after syphilis treatment
treponemal pallidum particle agglutination or TP-PA
what treponemal test to order on CSF if concerned for syphilis?
Order VRDL on CSF fluid to rule out neurosyphilis.
positive nontreponemal testing after syphilis tx chart
Tx for primary syphilis (chancre)
Penicillin G (IM) x 1 dose OR doxycycline 14 days
Tx for secondary syphilis (diffuse rash)
Penicillin G (IM) x 1 dose OR doxycyline 14 days
Tx for latent (asymptomatic) syphilis - early and late latent
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.
Tx for tertiary syphilis (Cardiovascular syphilis, gummas)
Aqueous Penicillin G (IM) q4h X 14 days
or ceftriaxone 14 days
When can we get false positive RPR?
SLE (elevated ANA tier)
Best test for chancre
check dark field microscopy. Checking RPR too soon won’t have enough time for body to make antibodies so can miss it
When to order CSF analysis?
neurological or ophthalmological symptoms or any evidence of tertiary syphilis in other areas or has HIV infection.
Latent syphilis is defined as:
early
late
Tx for each
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.
Screening for Syphilis
RPR or syphilis antibody remain positive for life
Confirmatory testing if screening test is positive?
treponema pallidum enzyme immunoassay
how to know if reoccurrence or reinfection?
titers increase
Summary chart of treatment of syphilis
If pt had anaphylactic response to pencillin would still try to desensitize them and treat with penicillin.
Criteria for treatment for post exposure to syphilis
how does syphilis spread?
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.
what is the correct order of testing for syphilis antibodies?
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.
in pts who are allergic to penicillin and need treatment for primary syphilis what to give instead?
doxycycline is preferred as alternate over azithromycin given increasing resistance in many areas.
positive nontremponemal testing after syphilis treatment
positive nontremponemal testing after syphilis treatment
Name the post exposure prophylaxis to syphilis?
Single dose benzathine pencillin IM (same for primary, secondary and early latent syphilis)
tabes dorsalis is
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.
presents as sensory ataxia with lancinating pains that go upward. see absent lower extremity reflexes and impaired vibratory and position sensation.
Tabes dorsalis or tertiary syphilis.
ascending aorta dilation with aortic insufficiency and left heart failure.
Also has ascending aortic arch calficiation on CXR (not related to atherosclerosis)
cardiovascular syphilis. Seen years after infection.
Can be seen with tabes dorsalis.
Treatment of tertiary syphilis:
Treatment of neurosyphilis:
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
Treatment of congenital syphilis is
aqueous penicillin G 50K unit/kg/dose IV every 8-12 hrs for 10 days
heavy metal poisoning presentation
(on differential for tabes dorsalis because of presentation with impaired vibratory and position sense and absent lower extremity reflexes)
psychiatric abnormalities like irritability and neuropathies like wrist or foot drop.
Best test for tabes dorsalis or cardiovascular syphilis?
treponemal assays – remain 100% sensitive.
chancre is
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)
early neurosyphilis is
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
how to follow someone with neurosyphilis after treatment?
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
Treatment of primary and secondary syphilis if allergic to penicillin
doxycycline.
If someone fails to improve when treated for syphilis next thing to do is:
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
