Syphilis | Questions & Answers | 2010 Treatment Guidelines
Question 1: For congenital syphilis evaluation if a lab is not doing rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) testing, which specific test is recommended, immunoglobulin G (IgG), or immunoglobulin M (IGM)?
Question 2: The guidelines state that individuals exposed to early syphilis should be treated if the exposure occurred within 90 days prior to the diagnosis of the infected person. This is incorrect. The partner should be treated for any exposure to the infected patient that occurred within 90 days from the date when the partner is seen by the clinician. The date of diagnosis of the infected patient should not enter into the equation. The guidelines offer the wrong starting point from which to count back.
Question 3: How often does neurosyphilis occur with a negative rapid plasma reagin (RPR) (serum), negative cerebrospinal fluid nontreponemal (CSF VDRL) test, but positive CSF treponemal fluorescent treponemal antibody (FTA) test? This case involves a patient with high suspicion of of neurosyphilis, without known treatment in the past, and with a high protein white blood count in CSF.
Question 4: Why is a lumbar puncture (LP) not useful in latent syphilis, or syphilis of unknown duration?
Question 5: If treating a male for suspected syphilis, do we treat any partners at the same time, or await their tests?
Question 6: Why would CDC recommend a reverse serologic screening for syphilis, and what are the implications on treatment?
Question 7: Absent a clear history of recent chancre, how strictly should we document one year (365 days) for seroconversion or recent partners to differentiate early versus late latent syphilis, since treatment regimens for these conditions differ?
Question 8: Does rapid plasma reagin (RPR) or the Treponema pallidum particle agglutation (TP-PA) show positive first?
Question 9: How does CDC recommend management of patients with immunoglobulin G (IgG) treponema test positive, negative rapid plasma reagin (RPR) and positive second treponemal test? What does CDC recommend if the patient is a pregnant woman?
Question 10: Does CDC recommend only one round of treatment for syphilis, regardless of how long the patient has been infected or what stage is diagnosed?
Question 11: For treatment of late latent syphilis, how long is one week? That is, if a patient returns for penicillin dose two or dose three after six, eight, nine, or ten days, is it necessary to restart the series?
Question 12: What alternative antibiotics can be used for the treatment of syphilis, besides penicillin G or doxycycline?
Question 13: Why is azithromycin 2 g. not recommended as an alternative therapy for primary, secondary, and early latent syphilis in men who have sex with men (MSM)?
Question 14: Do we need to perform lumbar puncture (LP) for everyone presenting with HIV and a headache from primary syphilis?
Question 15: In late latent syphilis in HIV positive patients, should we still give benzathine penicillin 2.4 mil units weekly for three weeks?
Question 16: Currently we treat HIV positive persons who also have syphilis with bicillin 2.4 mil units weekly for three weeks. Do we now only need to provide one injection?