Syphilis

Canadian Guidelines on Sexually Transmitted Infections - Syphilis

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Diagnosis

1. Syphilis serology – mainstay of syphilis diagnosis
   • Syphilis enzyme immunoassay (EIA)

- Screening test in Alberta

- Measures IgM and IgG antibodies to Treponema pallidum (treponemal test)

- Usually remains positive lifelong even after successful therapy

• •    Rapid plasma reagin (RPR)

- In Alberta, RPR performed on all EIA positive specimens

- Measures cardiolipin antibodies (nontreponemal test)

- Reflects disease activity, indicator for treatment response and re-infection

• • Treponema pallidum particle agglutination test (TPPA)

- Confirmatory test in Alberta

- Performed on all EIA positive specimens when clients test positive for the first time

NB:  If high clinical suspicion for infectious syphilis but negative test result, repeat serology in 2-4 weeks. Syphilis serology may be false negative in early stages of disease.

2. Syphilis PCR of syphilitic lesions, chancres, skin and mucosal surfaces.

- Ulcers should also be tested for herpes simplex virus (HSV). Test for Chancroid +/- Lymphogranuloma venereum if syphilis and HSV negative and epidemiologic exposure (i.e. appropriate travel history or contact with a traveler).

- All patients with a diagnosis of syphilis should be tested for HIV.

Primary Syphilis

- Chancre – single painless genital ulcer (occasionally extragenital indurated ulcer) within 3 weeks of infection; may be multiple/painful (up to 30% co-infected with HSV)

- Regional lymphadenopathy 70-80%

- May resolve without treatment.

Secondary syphilis

- Highly infectious stage

- Multiple organ systems can be involved including generalized lymphadenopathy, hepatosplenomegaly, hepatitis, alopecia, oral lesions, pharyngitis, anterior uveitis, optic neuritis, meningitis, glomerulonephritis, periosteitis

- Cutaneous manifestations include macular/maculopapular/scaly lesions of face, torso and flexor aspects of extremities.

- Symptoms resolve without treatment within 6 months after primary infection.

Latent syphilis

- Seroreactivity without clinical evidence of disease:

Early < 1 year

Late > 1 year

Tertiary syphilis

- Cardiovascular disease, neurosyphilis, gumma

- Occurs years to decades after primary infection

Treatment failure

- Clinical progression or relapse of clinical symptoms or inadequate decline in RPR/VDRL titres.

- NB: Treponemal test usually remains positive lifelong even after successful therapy.

Primary, Secondary, Latent < 1 year duration (early)

- All sexual contacts of early syphilis should be tested and treated.

Treponema pallidum

ß-lactam allergy

Alternative in ß-lactam allergic pregnant patients

Latent > 1 year duration (late) or unknown duration

- Evaluation (including lumbar puncture) to rule out tertiary syphilis should be done in consultation with an Infectious Diseases/STI specialist prior to treatment.

Treponema pallidum

ß-lactam allergy

Alternative in ß-lactam allergic pregnant patients

Neurosyphilis, including ocular syphilis

- Recommend LP if:

• presence of neurologic or ophthalmic symptoms or signs
• previously treated patients without adequate serological treatment response
• tertiary syphilis

- Test CSF for:

• cell count and differential, protein
• VDRL and FTA-ABS.

Treponema pallidum

ß-lactam allergy