Updated: 3/3/2019

Syphilis (Adult)

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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)
      • 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  
    • doxycycline 
      • an alternative for treating syphilis in pencillin-allergic patients
Complications
  • Jarisch-Herxheimer reaction
    • flu-like syndrome after starting treatment for syphilis
      • due to toxins released by killed T. pallidum
  • Complications of tertiary syphilis
    • aortic insufficiency
    • tabes dorsalis
    • general paresis
 

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Questions (6)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.ID.57) A 33-year-old man presents to the infectious diseases clinic for follow-up. He was recently admitted to the hospital with fever, shortness of breath, and cough, and was found to have Pneumocystic jirovecii pneumonia and a new diagnosis of HIV. His CD4 count is 175, viral load is pending. As part of routine laboratory studies given his new diagnosis, an RPR was found to be positive with a titer of 1:64, and this is confirmed with a positive FTA-ABS. He is unsure when or how he acquired HIV or syphilis. His neurological examination is normal, and he has no symptoms. Which of the following is the most appropriate next step in management: Review Topic

QID: 102998
1

Perform lumbar puncture, treat based on presence or absence of CNS disease

0%

(0/0)

2

Treat with three weekly injections of penicillin, obtain titers in 3 months

0%

(0/0)

3

Treat with three weekly injections of penicillin, obtain titers in 6 months

0%

(0/0)

4

Treat with a single injection of penicillin, obtain titers in 3 months

0%

(0/0)

5

Treat with a single injection of penicillin, obtain titers in 6 months

0%

(0/0)

M2

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PREFERRED RESPONSE 3

(M2.ID.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? Review Topic

QID: 107202
FIGURES:
1

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

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(0/17)

2

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

24%

(4/17)

3

Lower sensitivity of the test during the early stages of infection

41%

(7/17)

4

Effects of alcohol on the test reactivity

0%

(0/17)

5

Effects of HIV infection on the test reactivity

29%

(5/17)

M2

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PREFERRED RESPONSE 2
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