Syphilis – 7/23/18

Carriann presented the case of a young woman with HIV (CD4 250 off ARVs) and prior syphilis s/p treatment five years ago who presented with constitutional symptoms and diffuse rash involving the palms and soles, found to have RPR 1:256 consistent with secondary syphilis!

Clinical Pearls 

  • Lues maligna or malignant syphilis is a rare manifestation of secondary syphilis in immunocompromised individuals and presents as an ulceronodular rash.
  • Syphilitic hepatitis is seen in ~10% of patients with secondary syphilis and presents as predominantly elevated alkaline phosphatase with normal or mildly elevated transaminases.
  • Neurosyphilis can occur at any point after infection with syphilis!
  • Treatment success is defined as a four-fold drop in nontreponemal titers (ie RPR).



Keep in mind the following principles:

  • Treponemal tests remain positive long-term
  • Non-treponemal tests can become negative after treatment.  They are useful for treatment monitoring because they can be quantitative
  • Both tests can be falsely negative early in disease course so repeat tests if clinical suspicion remains
  • Screening algorithm

Treatment monitoring:

  • Jarisch-Herxheimer reaction is a self-limited condition that can occur in ~10-35% of patients within 24 hours of treatment with antibiotics.
  • A four-fold decline in titers (2 dilutions) is considered treatment success.
  • Monitor titers q 6-12 months post treatment.  Increasing titer is concerning for treatment failure, neurosyphilis, or reinfection!

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