Updated: 10/21/2020

Syphilis (Adult)

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Snapshot

rash
  • A 41-year-old man presents to the clinic complaining of an intensely pruritic rash over his torso, back, and arms including his palms. He also describes being concerned about patchy hair loss on his scalp as well as the presence of warty growths on his penis. His sexual history is notable for frequent sexual encounters with both male and female partners without the use of condoms. Physical exam is significant for a diffuse, erythematous maculopapular rash, patchy alopecia on his scalp, wart-like white lesions on the base of his penis, and bilateral inguinal lymphadenopathy. VDRL and FTA-ABS were positive.
Introduction
  • Classification
    • Treponema pallidum
      • spirochete
  • Epidemiology
    • demographics
      • most common during years of peak sexual activity
        • most new cases occur in men and women aged 20-29 years
      • recent rise in syphilis cases among men who have sex with men (MSM) community
    • co-infection of syphilis with HIV is high
    • location
      • genitourinary tract
    • risk factors
      • unprotected sex
      • IV drug use and needle-sharing
  • Pathogenesis
    • mechanism
      • T. pallidum rapidly penetrates intact mucous membranes or dermal abrasions and enters the lymphatics and blood to cause systemic infection
    • transmission
      • intimate contact with infectious lesions (most common)
      • blood transfusion
      • transplacentally from infected mother to fetus
  • Associated conditions
    • cardiovascular syphilis
      • aneurysm formation
    • neurosyphilis
  • Prognosis 
    • favorable prognosis for patients diagnosed with either primary or secondary syphilis
    • 20% of untreated patients with tertiary syphilis die of the disease
      • prognosis for tertiary syphilis depends on the extent of scarring and tissue damage
      • with adequate treatment, 90% of patients with neurosyphilis have a favorable clinical recovery
Presentation
  • Primary syphilis
    • painless chancre 
      • indurated edge
      • can visualize treponemes in fluid from chancre using dark-field microscopy
  • Secondary syphilis
    • disseminated disease
    • diffuse, maculopapular rash that involves the palms and soles
    • condylomata lata
      • smooth, painless, wart-like white lesions on genitals
    • lymphadenopathy
    • patchy alopecia
  • Tertiary syphilis
    • gummas
      • chronic granulomas
    • aortitis 
      • from destruction of the vasa vasorum
    • neurosyphilis
      • tabes dorsalis
    • Argyll Robertson pupil
      • pupil constricts with accommodation but is not reactive to light 
    • other symptoms
      • broad-based ataxia
      • positive Romberg
      • stroke without hypertension
  • Congenital syphilis 
    • facial abnormalities
      • rhagades (linear scars at angle of mouth)
      • nasal discharge
      • saddle nose
      • notched Hutchinson teeth
      • mulberry molars
      • short maxilla
    • saber shins
    • sensorineural deafness
Studies
  • Labs
    • nonspecific serologic testing
      • VDRL (venereal disease research laboratory)
        • can test in CSF with neurologic or otologic involvement of syphilis 
      • RPR (rapid plasma reagent)
    • specific serologic testing
      • FTA-ABS (fluorescent treponemal antibody-absorption)
        • use to confirm diagnosis
  • Microscopy
    • dark-field microscopy 
      • visualize motile spirochetes
Differential
  • Herpes simplex virus
    • painful genital vesicles and ulcers
  • Haemophilus ducreyi
    • painful genital ulcer with exudate
  • Lymphogranuloma venereum
    • buboes
  • Klebsiella granulomatis
    • beefy red ulcer that bleeds on contact
Treatment
  • Medical
    • penicillin 
      • IM penicillin for primary or secondary syphilis and early latent syphilis  
      • IV penicillin G for late latent syphilis
        • if allergic to penicillin, patient should be desensitized  
      • if patient is pregnant and allergic to penicillin, patient should be desensitized 
        • high risk of stillbirth, neonatal death, and mental retardation
    • doxycycline 
      • an alternative for treating syphilis in pencillin-allergic patients
    • ceftriaxone 
      • an alternative for tertiary syphilis in penicillin-allergic patients 
    • densensitization to penicillin
      • can be attempted for tertiary syphilis but typically done in the intensive care setting under supervision of an allergy specialist
Complications
  • Jarisch-Herxheimer reaction
    • flu-like syndrome after starting treatment for syphilis
      • due to toxins released by killed T. pallidum
        • symptomatic treatment (NSAIDs and acetaminophen) 
  • Complications of tertiary syphilis
    • aortic insufficiency
    • tabes dorsalis
    • general paresis

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Questions (13)
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(M2.ID.15.4672) A middle-aged homeless male is brought to the emergency department for alcohol withdrawal. He is a poor historian who cannot recall any of his past medical history. Testing reveals that the patient is HIV positive. Notably, physical exam reveals the following skin rash on the patient’s bilateral palms (Figure A), and a lesion on the patient’s tongue (Figure B). Given these findings, RPR/VDRL tests are performed and return as non-reactive. A biopsy of the skin lesion yields the following organism on dark-field microscopy (Figure C). What is the explanation for the patient’s negative RPR/VDRL tests?

QID: 107202
FIGURES:
1

The patient’s symptoms are actually a result of his HIV infection

0%

(0/21)

2

Antibody excess leading to an imbalance of the antibody to antigen ratio

24%

(5/21)

3

Lower sensitivity of the test during the early stages of infection

43%

(9/21)

4

Effects of alcohol on the test reactivity

0%

(0/21)

5

Effects of HIV infection on the test reactivity

29%

(6/21)

M 5 D

Select Answer to see Preferred Response

(M2.ID.14.59) A 26-year-old immigrant from Mexico presents to your clinic for a physical. He tells you that several weeks ago, he noticed a lesion on his penis which went away after several weeks. It was nontender and did not bother him. He currently does not have any complaints. His temperature is 97.9°F (36.6°C), blood pressure is 139/91 mmHg, pulse is 87/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable and shows no evidence of any rash. A VDRL and FTA-ABS test are both positive. What is the most appropriate management of this patient?

QID: 103000
1

Acyclovir

3%

(2/65)

2

Azithromycin and ceftriaxone

25%

(16/65)

3

Doxycycline

12%

(8/65)

4

No treatment indicated

48%

(31/65)

5

Penicillin

9%

(6/65)

M 7 E

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Evidence (9)
EXPERT COMMENTS (14)
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