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).

Diagnosis:

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!