Download - Clinical education: Syphilis
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Clinical education:
Syphilis
Dr Melanie Bissessor, March 2021
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Syphilis
Treponema pallidum
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Syphilis Staging • Early syphilis (< 2 years)
– Primary– Secondary – Early Latent
• Late syphilis (>2 years) ØLate latent syphilis-serology available but greater
than 2 years old• Latent syphilis of unknown duration-no previous
serology available
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Syphilis Staging • Tertiary Syphilis (10-20 years)
– Neurosyphilis– Cardiovascular Syphilis – Gumatous Syphilis
• Congenital Syphilis
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Primary Syphilis
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Secondary Syphilis
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Secondary Syphilis
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Diagnosis – Serologic • Treponemal Specific Tests
– Chemiluminescence Immunoassay (CLIA)• IgM/IgG
– T.pallidium Particle Agglutination Assay (TPPA)
– T.pallidium Haemagglutination Assay (TPHA)– Fluorescent Treponemal Antibody Absorbed
(FTA-ABS)
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Diagnosis – Serologic • non-treponemal serologic tests
– Rapid Plasma Reagin (RPR) Test – provide a titre, index of disease activity
• 1:2; 1:4; 1:8; 1:16; 1:32; 1:64; 1:128; 1:256…– biologic false positives
• autoimmune disease, pregnancy, viral infections
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Non-Treponemal Tests • Rapid Plasma Reagin Test (RPR)
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Diagnosis- Direct Identification • Dark Ground Microscopy
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Diagnosis- Direct Identification • Polymerase Chain Reaction (PCR)
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Treatment • Early Syphilis (<2 years)
– Benzathine Penicillin 2.4 mIU imi once
– Doxycycline 100mg BD for 14 days
• Late Syphilis (>2 years or Unknown Duration)– Benzathine Penicillin 2.4
mIU imi. weekly for 3 weeks
– Doxycycline 100mg BD for 28 days
• It is always preferable to treat with Benzathine penicillin over Doxycycline due to compliance issues.
• Use Doxycycline only if has penicillin allergy and not pregnant
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Jarish-Herxheimer Reaction • transient flu-like reaction (headache, fever, chills,
myalgia) following initiation antimicrobial therapy for syphilis. (within 24 hours)
• self-limiting (<24 hours)• mainly in early syphilis (mostly in secondary)• manage with rest, paracetamol• potentially life threatening, inpatient syphilis treatment
is recommended in cardiovascular, neurosyphilis, ocular syphilis, pregnancy
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Successful Treatment• resolution of symptoms• four fold drop in RPR titre e.g.• 1: 64 to 1: 16 or less• drop usually occurs after 3-6 months after treatment• serofast
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Indications for CSF Examination
• CNS involvement: Øvisual disturbancesØhearing loss/changesØgait or balance changesØ severe headache
• treatment failure
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Basic Staging Signs and Symptoms Yes No
PrimaryChancre /UlcerDGI/Tp PCR + RPR +/-CLIA/TPPA +/-
SecondaryRPR +CLIA/TPPA + DGI/Tp PCR may be + from mucous patch or condylomata lata
Latent
serology in past 2 years
Yes No
Early latent <2 years
Latent Unknown Duration or Late Latent >2 years
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Specific Serology • TPPA and CLIA• remain positive for the rest of life• rare to lose these antibodies• once positive cannot be used to determine
reinfection
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Reinfection • presence of symptoms• TpPCR positive• DGI positive• asymptomatic • RPR =/> 4 four fold rise in titre from baseline• RPR = 2 fold rise
– parallel testing may be requested from lab
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Case 1 • 29 year old• MSM• No symptoms• First STI screen
Date CLIA TPPA RPR DGI PCR Sx Stage Rx
27-10-17
Reactive Reactive Non-Reactive
ASx ? ?
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Case 2 • 36 year old• painless penile ulcer x 4 days• regular STI screening every 3 months
Date CLIA TPPA
RPR DGI Tp PCR Sx Stage Rx
12-08-17 Reactive Reactive Non-Reactive
Spirochetes Not Detected
Detected Ulcer
20-08-17 Reactive Reactive 1:8 Day of Tx
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Case 3• 52 year old transgender female• Multiple partners• Regular STI screening• On PREP• p/h of syphilis • No symptoms today
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Case 3
Date CLIA TPPA RPR DGI PCR Sx Stage
Rx
23-04-16
Non-Reactive
ASx
12-01-17
Reactive Reactive 1:4 Spirochetes Detected
Positive Genital Ulcer
? ?
14-05-17
Reactive Reactive Non-Reactive
ASx ?
22-02-18
Reactive Reactive 1:256 ASx ? ?
10-06-18
Reactive Reactive 1:8 ASx ?
15-2-19 Reactive Reactive 1:16 ASx ? ?
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Case 4 • 46 year old female• Recently returned traveller• Last STI screen 3 years ago• Treated as a syphilis contact in UK
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Case 4 • Very stressed• No job and couch surfing• Recurrent cold sores and mouth ulcers
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Case 4
Date CLIA TPPA RPR DGI Tp PCR Sx Stage
25-09-16 Reactive Reactive 1:32 ASx ?
28-03-17 Reactive Reactive 1:2 ASx ?
18-04-20 Reactive Reactive 1:256 Detected WhitePatches-Tongue
?