Presentation on theme: "Jayne Howard Clinical Coordinator HIV Ambulatory Care The Alfred"— Presentation transcript:
1Jayne Howard Clinical Coordinator HIV Ambulatory Care The Alfred SYPHILISJayne HowardClinical CoordinatorHIV Ambulatory CareThe Alfred
2Current situation / epidemic 1st quarter 199 cases of syphilis total, of which 102 were infectious syphilis- 98 were male, 89 (90%) indicated a male partner- among males reporting male partner, 85% reported from casual partner, 10% from a regular partner2nd quarter 97Source: Victorian Infectious Diseases Bulletin, DHS, June 2007.
3Syphilis serology - Alfred Number of testsCourtesy Jenny (micro) and Denis Spelman.
4Syphilis serology - Alfred Number of positivesCourtesy Denis Spelman and VIDRL. *2007 to end July
5A bacteria A member of the spirochete family Treponema Pallidum
6TransmissionDirect contact with infectious lesions of skin and mucous membranesMost commonly occurs during sexual activityUnprotected vaginal, anal or oral intercourseRarely occurs during non sexual activityBlood transfusionsVertical transmission from mother to child during pregnancyDirect contact with an infectious lesion
7Clinical stages of syphilis Primary SyphilisChancre (sore) develops between days after exposure (3 weeks) at the site of infectionMost are painlessCan often go undetectedUsually heals within few weeks(3-6 weeks)Occasionally more than 1 sore may develop (HIV +ve individuals)Lymphadenopathy (swollen glands)Infectious periodThe stages of syphilis can produce symptoms or be asymptomatic. These stages can often overlap.Chancre can be found in or around the vagina, the glans penis, tongue, lips or fingersFairfield Hospital and MSHC Photo Collection.
8Secondary syphilis Rash Infection spreads through the blood and lymph systemUsually between 2-6 week weeks after the chancreCommon symptoms include-Fever and a rashRashdark pink or copper colouredpalms of handsSoles of the feetAbdomenAlso lymphadenopathy, headache, malaise, anorexiaLesions in mucous membranes e.g. mouth,vaginasnail track ulcers and condyloma lataChancre may still be present
9Secondary syphilis Less common symptoms include- Hair loss (alopecia) with a moth eaten appearanceHepatitis, GI ulcerationArthritis and joint problemsRenal symptomsNeurologic abnormalities, headaches,memory loss (common in HIV+ve individuals)Eye and ear abnormalitiesSymptoms usually resolve around 3-12 weeks25% of symptoms will recur in the 1st year (some up to 4 years)Infectious period
10Secondary syphilisFairfield Photo Collection, Up to Date, MSHC collection
11Latent and Tertiary Syphilis Asymptomatic infection, no clinical signs of illness with positive serology (blood tests)Divided into-Early latent: Within the first 2 years from transmissionBased on possibility of relapses, potentially infectiousLate Latent: Greater than 2 years duration(US Public Health Service, CDC: > 1 year)Non infectious period, however transmission from mother to child can occur up to 4 yearsTertiaryNon infectious period years1/3 patients will develop cardiovascular involvement, neurosyphilis, gummatous syphilisUntreated syphilis – 10% developed cardiovascular syphilis, 16% gummatous syphilis, 6.5% symptomatic neurosyphilis.
12Clinical stages of syphilis Acquisition(~30%)1o2o2o3o2 years1 to 30 years:If untreated occurs in 40%, 25% clinically recognisableIncubation period10-90 days(average 21 days)Weeks to few monthsEpisodes may recur(occurs in 25%)Early syphilis(infectious)Late syphilis(non-infectious)
13Syphilis and HIV Similar mode of transmission Often more than 1 chancre (up to 70%)May be larger and deeperHIV +ve individuals may present with both primary and secondary lesions (approx 25%)Transient increase in HIV viral load and decrease in CD4 countResolves after the infection is treatedNeurological symptoms are more common in the early stages of syphilis in HIV+ve individualsZetola and Klausner. Syphilis and HIV Infection: An Update. CID 2007;44:
14Syphilis and HIVPresence of one is risk factor for acquiring the otherPresence of one increases the risk of transmission of the otherAll patients with syphilis should have a HIV testAll patients with HIV infection should have syphilis testing-upon entry to care / diagnosisannuallymore often if risk factors
16Diagnosis and Testing Syphilis is known as the “Great Mimicker” Good sexual history and examinationIdentification of the bacteria (treponeme) from infectious lesion(ability to recognize from other spirochetes)Most cases rely on specific blood testsSerological testingVDRL=Venereal Disease Research LaboratoryRPR=Rapid Plasma ReaginBeware of false positive results from other illness+ve in 75% primary100% secondary
17Diagnosis and Testing Specific treponemal tests FTA Antibody-Fluorescent treponemal antibody absorptionTPHA test- Treponemal pallidum haemagglutination assayTPPA test- Treponemal pallidum particle agglutination assayTreponemal 1gG EIA- Recombinant based IgG & IgM EIABeware of false positive resultsTreponemal tests do not differentiate between other treponeme speciesNeurosyphilis testing includes-Positive serology (blood tests)Clinical neurological symptoms (headache, confusion, memory loss)+/- findings in the cerebrospinal fluid (CSF) following lumbar punctureDecisions to perform a lumbar puncture may vary between specialists
18Treatment recommendations – Early syphilis (Primary, Secondary, Early Latent) Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004Therapeutic Guidelines, 2006MSHC Treatment Guidelines, 2005
19Treatment recommendations – Late syphilis (syphilis > 2 years or unknown duration) Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004Therapeutic Guidelines, 2006MSHC Treatment Guidelines, 2005
20Treatment recommendations – Neurosyphilis Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004Therapeutic Guidelines, 2006MSHC Treatment Guidelines, 2005“Seek Specialist Advice”
21Penicillin treatment issues Penicillin is the treatment of choiceJarisch-Herxheimer reactionAn acute reaction to penicillin treatment (not an allergy )fever, headache, myalgia and other symptomsUsually occurs within 24 hours (6-12 hours) of therapy for syphilisResolves after 24 hoursPrednisolone may be used to reduce the likelihood of a reactionPenicillin allergyA potential riskDesensitization to penicillin can be undertakenCAUTION
22Clinical follow-upAll patients should return to the clinic at 3, 6 and 12 months. Up to 24 months for HIV+ve individualsRepeat blood tests and a clinical examination will be performedRPR should drop 4 fold by 6 months(Test of cure)Will become negative in approx 70% primary 55% secondaryRe-treatment may be necessary (re-infection must be excluded)Health education and safe sex counsellingNeurosyphilisSeek specialist adviceCSF abnormalities may persist for longer in HIV+ individuals
23Management of contacts Syphilis is a notifiable infectionContact tracing (partner notification) should be undertaken-Notify all sexual contacts for the past 3 months for patients with primary syphilisPatients with secondary syphilis should notify all contacts within the last 2 yearsTreatment of contactsTreat all sexual contacts of patients with primary and secondary syphilis (infectious period) even if the blood test is negativeSexual contacts greater than 12 months ago require treatment if their blood test is positive for syphilisHealth education and safe sex counselling
24Case 1 45yo MSM HIV June 2006 CD4 495, 24%. HIV VL 1600 Feb 2007, visited his GP for HIV monitoring and sexual health screenNo clinical signs of illnessSyphilis blood tests positive,EIA +, RPR 1024Last recorded syphilis test was neg, June 06
25Case 1Single dose of benzathine penicillin was given intramuscular (IM)Repeat blood tests were performed at 3,6 months (test of cure)May 07, RPR 16August 07, RPR 16Treatment successful to date..
26Case 2 50 yo train driver, MSM October 2006 patient referred to Alfred HIV diagnosed Oct 05CD4 count 510, 25%. HIV VL >100,000Syphilis testing performed, EIA +, RPR 64No clinical signs or symptomsTreated with a single dose of benzathine penicillin IMLost to follow upOctober 2006 patient referred to Alfred12 month history multiple non-tender genital ulcers4 month history of bilateral hearing impairment4 week history of mouth ulcersS.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster
27Case 2 Syphilis testing repeated EIA +, RPR 512Lumbar puncture was performedCSF Syphilis serology was positiveSwabs from penile and oral lesionsNegativeTreated with intravenous (iv) benzylpenicillin and oral prednisoloneFollowing treatmentHearing improvedUlcers healingUnfortunately was lost to follow up. Unable to perform test of cureS.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster
28Conclusion Alternate treatments Azithromycin Ceftriaxone Penicillin best treatmentno resistanceallergyAlternate treatmentsAzithromycinCeftriaxoneresistanceHIV and syphilisBoth conditions increasing in incidenceOften occur togetherVariety of clinical presentationsIn generaldiagnosis and treatment similar as in HIV-uninfected patientsSome studies have shown treatment failures are common in HIV and syphilis so treat with caution and close follow up
29Acknowledgements Further reading: Dr Jonathan Darby, Infectious Diseases Registrar at The AlfredHIV Data Team at The AlfredFurther reading:Sexual Health Medicine, 2005Australasian Contact Tracing Manual 3rd Ed, 2006National Management Guidelines for Sexually Transmissible Infections, 2002