Clinical Approach on Syphilis: Diagnosis & Treatment

นายแพทย์อนพุงศ์ ชิตวรากรสมาคมแพทย์โรคตดิตอ่ทางเพศสมัพนัธ์แห่งประเทศไทยท่ีปรึกษาส านกัโรคเอดส์และโรคติดตอ่ทางเพศสมัพนัธ์

SCC@TropMed

Primary syphilis: diagnosis

1. clinical characteristic of chancre: indurated,

well defined, painless, clean base ulcer

2. Dark field examination positive

3. VDRL or RPR positive in 50-70%

4. FTA-Abs positive in 70-90%

Secondary Syphilis: general clinical manifestation

• Constitutional symptom: malaise, fever, headache, anorexia, nausea, vomiting

• Generalized lymphadenopathy: painless, discrete, rubbery on palpation

Condyloma lata, Dark ground: POSITIVE

Mucous patchDark field: POSITIVE

Moth eaten alopeciaRPR, VDRL, TP: POSITIVE

Secondary syphilis:

Specific clinical manifestation

1. Skin rash: macular, maculopapular, papular,

papulosquamous, pustualar, (non-itching,

symmetrical)

2. Condyloma lata: papular lesions in intertrigineous

area which erode

3. Mucous patch at genital or oral cavity

4. Moth eaten alopecia

Diagnosis:

1. Typical lesion with reactive non-treponemal test

(VDRL, RPR)

2. Atypical lesion with positive non treponemal of >1:16

or if >1:16, should be confirmed with positive

treponemal test (FTA Abs or TPHA)

Latent syphilis:

1. Early latent : less than 1

year duration

2. Late latent: > 1 year or

unknown duration

Diagnosis:

1. Non treponamal test

and treponemal test

reactive

2. No abnormal finding

from physical

examination and other

investigations

MSM: HIV prevalence and incidence by age group

and calendar year: SCC @TropMed (27 Oct 2015)

21.8

27.728.0 27.6

24.125.925.526.0

31.1

25.724.4

26.929.2

26.5

7.95.7

3.1

0.0

3.92.7

4.0 5.1 5.6 5.3 5.8 4.9 4.9 3.9

0

10

20

30

40P

reva

len

ce (

%)

Inci

de

nce

pe

r 1

00

pe

rso

n-y

ear

s prevalence

Age Group Calendar Year

10.110.7

12.9

6

3.2

6.2

4.4

8

11.710.7

12.7

15.416.3

3.9 43

0 01

0.3

4 3.9 4.23.7 4.1 4.4

0

5

10

15

20

<=21 22-29 >=30 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pre

vale

nce

(%

)In

cid

en

ce p

er

100

pe

rso

n-y

ea

rs

prevalence incidence

Age Group Calendar Year

Syphilis: Syphilis prevalence and incidence by age group and calendar year

4.8

7.28.2

5.3

1.6

3.12.5

4.5

8.3

6.77.5

10.4 10.1

0

5

10

15

20

<=21 22-29 >=30 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pre

vale

nce

(%

)In

cid

en

ce p

er

100

pe

rso

n-y

ea

rs prevalence

Age Group Calendar Year

HIV-Syphilis Co-infection: prevalence by age group and year

Syphilis: treatment

• Early syphilis: primary, secondary and early latent syphilis

• Benzathine penicillin 2.4 M unit IM, single dose

• Alternative: tetracycline 500mg. qid. 14 days or doxycycline 100mg. bid. 14 days or erythromycin 500mg. qid. 14 days

Syphilis: treatment

• Late syphilis: latent syphilis

• Benzathine penicillin 2.4 M unit IM, weekly for 3 consecutive weeks

• Alternative: tetracycline 500mg. qid. 28 days or doxycycline 100mg. bid. 28 days or erythromycin 500mg. qid. 28 days

Syphilis: follow up

• Quantitative non-treponemal test (VDRL or RPR) for every 3 months in year 1, every 6 months in year 2 after treatment.

• Additional once a year in case of reactive test.

Indication for retreatment: syphilis

• Clinically persist or relapse

• Increase in VDRL, RPR titer of > 4 folds

• 1 year after treatment, RPR or VDRL titer of >1:8 failed to show 4 folds decrease

• Retreatment as late syphilis

0

50

100

150

200

250

300

350

0 50 100 150 200 250

183 d

105 d

137 d

242 d

323 d

153 d

Data cut-off:End of Jun 2016

SCC Syphilis Referrals, Jan 2015 – Jun 2016: Treatment Delay (days)

Clients presented with referral documents (2015 n=102, 2016 6M n=108)Treatment Delay = Time from referral site diagnosis (Lab Report date) to SCC Visit date

Clients

Jan 2015 Dec

Jan 2016 Jun

Days

Treatment Delay (days)

Mean 15.7

Median 4

25-75 IQR

1-11

Min 0

Max 323

790 menavailable both HIV and TP result

Prozone phenomenon

• Occurred in 1-2 % of secondary SY

• Typical lesion of secondary sy but non reactive non-treponemal test (VDRL, RPR)

• Because of excess amount of anticardiolipin antibody

• Diluting serum should be performed to overcome the phenomenon

Jarisch- Herxheimer Reaction

• Following the treatment of primary or secondary sy

• Occure within few hours after treatment and subsides within 24 hours

• Triggered by endotoxin or allergy phenomenon

Jarisch- Herxheimer ReactionClinical manifestation

• Fever, chill, malaise, arthralgia, myalgia, headache, nausea

• Intensification of skin and mucous membrane lesion

• Increase in metabolic and heart rate

Biological false positive

• Reactive non-treponemal test (VDRL, RPR), but treponemal test (FTA-Abs, TPHA) non reactive

Acute BFPDuration of < 6 monthsAssociated with: 1. Acute infection (bacteria,viral, protozoa)2. Immunization, vaccination

Chronic BFP

Duration of > 6 months

Associated with:

1. Chronic infection:

Leprosy, malaria,

Autoimmune diseases

2. Intravenous drug users

3. normal, old age