2Diagnostic Tests Definitive: darkfield microscopy or DFA DFA- from scraping of lesionsDarkfield not readily availableHigh false negativePresumptive diagnosis with treponemal and nontreponemal testsMust use BOTHNontreponemal test for screeningTreponemal test to establish presumptive dx
3Nontreponemal Tests VDRL Venereal Disease Research Lab RPR Rapid Plasma ReaginART Automated Reagin TestInexpensive, rapid, quantitative results (Ab titer)Monitor response to therapyMust confirm positives with treponemal testAttributed to Albrecht Dürer (1496). It is possible that this could be an early work of Durer, or just as likely the work of his master, Wolgemut. The 1484 refers to a planetary conjunction, not the date of the print. The appearance of Scorpio indicates that the author of the medical tract of which this is an illustration regarded the disease as the product of unfavourable planetary alignment. They didn't call it syphilis then, referring to it as the 'French' or 'Neopolitan' disease. The two coats of arms to the left and the right are those of the city of Nürnberg
4Nontreponemal TestsFalse Positives: viral infections, lymphoma, TB, endocarditis, connective tissue dz, pregnancy, IV drug use, Wharton jelly contamination of cord.Do not delay treatment awaiting confirmationAdequate treatment:4 fold titer decrease by 6mosNegative by 1yr (congenital 2yrs)Relapse:4 fold increase in titer
5Nontreponemal TestsLow-titer false-positive nontreponemal test may be seen in pregnancyPersistently negative treponemal test confirms false positive
6Treponemal Tests FTA-ABS Fluorescent Treponemal Antibody Absorption TP-PA T pallidum particle agglutinationMost pts remain positive for lifeCorrelate poorly with dz activityFalse positives with other spirochetal diseasesDifferentiate by using VDRLYaws, pinta, leptospirosis, rat-bite fever, relapsing fever, Lyme dz
7CSF Evaluation VDRL test of choice Highly specific, but insensitive Negative result does not R/O neurosyphilisReactive test may be result of antibodies crossing blood-brain barrierElevate CSF WBC and proteinTreatment of congenital syphilis nearly always necessitates treatment of CNS involvement*
8All patients who have syphilis should be tested for: HIV
9Screening During Pregnancy VDRL or RPR early and again at deliveryIn areas of high prevalence screen also at 28WGAAny woman delivering stillborn >20WGA
10Treatment of pregnant woman PCN G 2.4 million Units IM weekly X3wksTreated 4wks prior to delivery4fold decrease in 6mosThere were originally no effective treatments for syphilis. The Spanish priest Francisco Delicado wrote El modo de adoperare el legno de India (Rome, 1525) about the use of Guaiacum in the treatment of syphilis. He himself suffered from syphilis. Nicholas Culpeper recommended the use of heartsease (wild pansy), an herb with antimicrobial activities.[not in citation given] Another common remedy was mercury: the use of which gave rise to the saying "A night in the arms of Venus leads to a lifetime on Mercury".
11Treatment of Newborn Followup Aqueous Penicillin G For neurosyphilis 50,000 U/kg IV q12 X10 daysFor neurosyphilisAdd 3 weekly doses IMNontreponemal test q2mos until decreases 4 foldIf increasing or perisitently stable titers 6-12mos after treatmentReevaluate including CSF, 10-days penicillinFollowup
12Hutchinson's triad is named after Sir Jonathan Hutchinson (1828–1913) Hutchinson's triad is named after Sir Jonathan Hutchinson (1828–1913). It is a common pattern of presentation for congenital syphilis, and consists of three phenomena: interstitial keratitis , Hutchinson incisors, and eighth nerve deafness.