Review Question - QID 102998

This patient presents following a new diagnosis of HIV. He is found to have latent syphilis of unknown duration without neurologic signs or symptoms. In this instance, and for patients who are HIV negative, the management is to treat with weekly penicillin for three weeks, and obtain titers in 6 months to assess response to treatment.

Syphilis manifests as primary, secondary, tertiary, and latent disease. In patients with no active signs or symptoms, and who have had the disease for an unknown period of time (e.g. unknown possible source and no recollection of symptoms), this is termed "latent syphilis of unknown duration", and is managed similarly to late (tertiary) syphilis. In HIV-infected patients, this should include a CSF evaluation if neurosyphilis is suspected, as in HIV-negative patients. The standard treatment includes 3 weekly IM injections of 2.4 million units of benzathine penicillin. Titers should be checked at 6 months to prove infection clearance.

Mattei et al. discuss the re-emergence of syphilis as an important pathogen in clinical medicine. They mention specific increased incidence among men who have sex with men (MSM); among high-risk populations, they emphasize the importance of screening with RPR testing. New diagnostic techniques are being studied, including point-of-care testing for resource limited settings and a novel CSF marker to detect neurosyphilis. Penicillin is the optimal treatment, providing no patient allergies.

Gonzalez-Lopez et al. conducted a retrospective analysis to determine predictors of disease response among patients with syphilis; roughly half were co-infected with HIV and roughly half were MSM. Approximately one quarter of patients experienced treatment failure; risk factors for treatment failure included male sex, HIV positivity, and having late stage syphilis. Over the 2-year follow up period, response rates were similar between HIV-positive and HIV-negative patients.

Incorrect Answers:
Answer 1: This patient displays no overt signs or symptoms of neurosyphilis. Although previously the practice had been to perform CSF sampling on all patients coinfected with HIV and syphilis, this has recently been questioned.
Answer 2: No scenario would be managed in this specific way.
Answer 4: A single dose of penicillin with response assessment at 3 months would be the appropriate management of primary or secondary syphilis.
Answer 5: A single dose of penicillin with response assessment at 6 months would be the appropriate management of early latent syphilis.