1. Jayne Howard Clinical Coordinator HIV Ambulatory Care The Alfred
SYPHILIS
Jayne Howard
Clinical Coordinator
HIV Ambulatory Care
The Alfred

2. Current 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 partner
2nd quarter 97
Source: Victorian Infectious Diseases Bulletin, DHS, June 2007.

3. Syphilis serology - Alfred
Number of tests
Courtesy Jenny (micro) and Denis Spelman.

4. Syphilis serology - Alfred
Number of positives
Courtesy Denis Spelman and VIDRL. *2007 to end July

5. A bacteria A member of the spirochete family Treponema Pallidum

6. Transmission
Direct contact with infectious lesions of skin and mucous membranes
Most commonly occurs during sexual activity
Unprotected vaginal, anal or oral intercourse
Rarely occurs during non sexual activity
Blood transfusions
Vertical transmission from mother to child during pregnancy
Direct contact with an infectious lesion

7. Clinical stages of syphilis
Primary Syphilis
Chancre (sore) develops between days after exposure (3 weeks) at the site of infection
Most are painless
Can often go undetected
Usually heals within few weeks(3-6 weeks)
Occasionally more than 1 sore may develop (HIV +ve individuals)
Lymphadenopathy (swollen glands)
Infectious period
The 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 fingers
Fairfield Hospital and MSHC Photo Collection.

8. Secondary syphilis Rash
Infection spreads through the blood and lymph system
Usually between 2-6 week weeks after the chancre
Common symptoms include-
Fever and a rash
Rash
dark pink or copper coloured
palms of hands
Soles of the feet
Abdomen
Also lymphadenopathy, headache, malaise, anorexia
Lesions in mucous membranes e.g. mouth,vagina
snail track ulcers and condyloma lata
Chancre may still be present

9. Secondary syphilis Less common symptoms include-
Hair loss (alopecia) with a moth eaten appearance
Hepatitis, GI ulceration
Arthritis and joint problems
Renal symptoms
Neurologic abnormalities, headaches,memory loss (common in HIV+ve individuals)
Eye and ear abnormalities
Symptoms usually resolve around 3-12 weeks
25% of symptoms will recur in the 1st year (some up to 4 years)
Infectious period

10. Secondary syphilis
Fairfield Photo Collection, Up to Date, MSHC collection

11. Latent 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 transmission
Based on possibility of relapses, potentially infectious
Late 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 years
Tertiary
Non infectious period years
1/3 patients will develop cardiovascular involvement, neurosyphilis, gummatous syphilis
Untreated syphilis – 10% developed cardiovascular syphilis, 16% gummatous syphilis, 6.5% symptomatic neurosyphilis.

12. Clinical stages of syphilis
Acquisition
(~30%) 1o 2o 2o 3o
2 years
1 to 30 years:
If untreated occurs in 40%, 25% clinically recognisable
Incubation period
10-90 days
(average 21 days)
Weeks to few months
Episodes may recur
(occurs in 25%)
Early syphilis
(infectious)
Late syphilis
(non-infectious)

13. Syphilis and HIV Similar mode of transmission
Often more than 1 chancre (up to 70%)
May be larger and deeper
HIV +ve individuals may present with both primary and secondary lesions (approx 25%)
Transient increase in HIV viral load and decrease in CD4 count
Resolves after the infection is treated
Neurological symptoms are more common in the early stages of syphilis in HIV+ve individuals
Zetola and Klausner. Syphilis and HIV Infection: An Update. CID 2007;44:

14. Syphilis and HIV
Presence of one is risk factor for acquiring the other
Presence of one increases the risk of transmission of the other
All patients with syphilis should have a HIV test
All patients with HIV infection should have syphilis testing-
upon entry to care / diagnosis
annually
more often if risk factors

15. STIGMA GUIDELINES NSW,2005

16. Diagnosis and Testing Syphilis is known as the “Great Mimicker”
Good sexual history and examination
Identification of the bacteria (treponeme) from infectious lesion(ability to recognize from other spirochetes)
Most cases rely on specific blood tests
Serological testing
VDRL=Venereal Disease Research Laboratory
RPR=Rapid Plasma Reagin
Beware of false positive results from other illness
+ve in 75% primary
100% secondary

17. Diagnosis and Testing Specific treponemal tests
FTA Antibody-Fluorescent treponemal antibody absorption
TPHA test- Treponemal pallidum haemagglutination assay
TPPA test- Treponemal pallidum particle agglutination assay
Treponemal 1gG EIA- Recombinant based IgG & IgM EIA
Beware of false positive results
Treponemal tests do not differentiate between other treponeme species
Neurosyphilis testing includes-
Positive serology (blood tests)
Clinical neurological symptoms (headache, confusion, memory loss)
+/- findings in the cerebrospinal fluid (CSF) following lumbar puncture
Decisions to perform a lumbar puncture may vary between specialists

18. Treatment recommendations – Early syphilis (Primary, Secondary, Early Latent)
Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004
Therapeutic Guidelines, 2006
MSHC Treatment Guidelines, 2005

19. Treatment recommendations – Late syphilis (syphilis > 2 years or unknown duration)
Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004
Therapeutic Guidelines, 2006
MSHC Treatment Guidelines, 2005

20. Treatment recommendations – Neurosyphilis
Sexual Health Guidelines – Royal Australasian College Physicians, Sexual Health Chapter, 2004
Therapeutic Guidelines, 2006
MSHC Treatment Guidelines, 2005
“Seek Specialist Advice”

21. Penicillin treatment issues
Penicillin is the treatment of choice
Jarisch-Herxheimer reaction
An acute reaction to penicillin treatment (not an allergy )
fever, headache, myalgia and other symptoms
Usually occurs within 24 hours (6-12 hours) of therapy for syphilis
Resolves after 24 hours
Prednisolone may be used to reduce the likelihood of a reaction
Penicillin allergy
A potential risk
Desensitization to penicillin can be undertaken
CAUTION

22. Clinical follow-up
All patients should return to the clinic at 3, 6 and 12 months. Up to 24 months for HIV+ve individuals
Repeat blood tests and a clinical examination will be performed
RPR should drop 4 fold by 6 months(Test of cure)
Will become negative in approx 70% primary 55% secondary
Re-treatment may be necessary (re-infection must be excluded)
Health education and safe sex counselling
Neurosyphilis
Seek specialist advice
CSF abnormalities may persist for longer in HIV+ individuals

23. Management of contacts
Syphilis is a notifiable infection
Contact tracing (partner notification) should be undertaken-
Notify all sexual contacts for the past 3 months for patients with primary syphilis
Patients with secondary syphilis should notify all contacts within the last 2 years
Treatment of contacts
Treat all sexual contacts of patients with primary and secondary syphilis (infectious period) even if the blood test is negative
Sexual contacts greater than 12 months ago require treatment if their blood test is positive for syphilis
Health education and safe sex counselling

24. Case 1 45yo MSM HIV June 2006 CD4 495, 24%. HIV VL 1600
Feb 2007, visited his GP for HIV monitoring and sexual health screen
No clinical signs of illness
Syphilis blood tests positive,EIA +, RPR 1024
Last recorded syphilis test was neg, June 06

25. Case 1
Single dose of benzathine penicillin was given intramuscular (IM)
Repeat blood tests were performed at 3,6 months (test of cure)
May 07, RPR 16
August 07, RPR 16
Treatment successful to date..

26. Case 2 50 yo train driver, MSM October 2006 patient referred to Alfred
HIV diagnosed Oct 05
CD4 count 510, 25%. HIV VL >100,000
Syphilis testing performed, EIA +, RPR 64
No clinical signs or symptoms
Treated with a single dose of benzathine penicillin IM
Lost to follow up
October 2006 patient referred to Alfred
12 month history multiple non-tender genital ulcers
4 month history of bilateral hearing impairment
4 week history of mouth ulcers
S.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster

27. Case 2 Syphilis testing repeated
EIA +, RPR 512
Lumbar puncture was performed
CSF Syphilis serology was positive
Swabs from penile and oral lesions
Negative
Treated with intravenous (iv) benzylpenicillin and oral prednisolone
Following treatment
Hearing improved
Ulcers healing
Unfortunately was lost to follow up. Unable to perform test of cure
S.J.Aitchison, K.M. Watson, A.M. Mijch. IAS Poster

28. Conclusion Alternate treatments Azithromycin Ceftriaxone
Penicillin best treatment
no resistance
allergy
Alternate treatments
Azithromycin
Ceftriaxone
resistance
HIV and syphilis
Both conditions increasing in incidence
Often occur together
Variety of clinical presentations
In general
diagnosis and treatment similar as in HIV-uninfected patients
Some studies have shown treatment failures are common in HIV and syphilis so treat with caution and close follow up

29. Acknowledgements Further reading:
Dr Jonathan Darby, Infectious Diseases Registrar at The Alfred
HIV Data Team at The Alfred
Further reading:
Sexual Health Medicine, 2005
Australasian Contact Tracing Manual 3rd Ed, 2006
National Management Guidelines for Sexually Transmissible Infections, 2002