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Evaluating Patients For Primary • Lesion appears 10-90 days after contact at site of exposure; may persist for 2-3weeks then resolves Clinical• Usually genitorectal Presentations but may be Ofextragenital, Primary depends Syphilis on exposure site • Clinical presentation typical or atypical • Typical: single painless, indurated, clean-based with rolled edges & bilateral painless adenopathy Sexual* History, Risk Assessment (past year): Physical Exam • Atypical: can mimic herpes & other genital ulcers • gender of partners • oral cavity •SEXUAL number of partners HISTORY, (new, anonymous, RISK ASSESSMENT serodiscordant & •PHYSICAL lymph nodes EXAM Patient with new genital ulcer or suspicious genital lesion • ~25% present with multiple lesions HIV status, exchange of sex for drugs or money) • skin • types of sexual exposure • palms & soles • recent STDs; HIV serostatus • neurologic * Herpes, , primary HIV ulcers, trauma & many non-STD • substance abuse • genitalia/pelvic causes of genital ulcers • use • perianal SEXUAL HISTORY, RISK ASSESSMENT & PHYSICAL EXAM History of syphilis prior syphilis (last serologic test & last treatment) † DIAGNOSTIC WORK-UP 1 • Darkfield (if available) • TP-PA or FTA-ABS to confirm reactive RPR or VDRL • Stat RPR (if available) • HSV culture or PCR Darkfield† • RPR or VDRL serology • HSV type-specific serology ~ 80% sensitive, varies with experience/skill of examiner & decreased sensitivity as lesion ages • HIV Test DIAGNOSTIC ISSUES IN PRIMARY SYPHILIS M M RPR/VDRL • A negative RPR/VDRL does not exclude the diagnosis of syphilis; only ~75-85% Multiple syphilitic ulcers, Syphilitic ulcer, corona sensitive in primary syphilis • Tests must be quantified to the highest titer & titer on the day of treatment must Positive Darkfield Negative or Not available be used to assess treatment response • Always use the same testing method (RPR or VDRL) in sequential testing; cannot compare titer from the two tests 2 • Tests lack specificity (biologic false positive); all reactive tests need to be ‡Primary Syphilis : § Reactive Stat RPR confirmed by a treponemal test for syphilis diagnosis Tre at , Follow-up**, Report & Partner Management M S Negative or Multiple syphilitic ulcers, glans Multiple syphilitic ulcers Not available resembling herpes 3 ‡Treatment of Primary Syphilis Yes Risk factors or 2 Recommended Regimen high clinical suspicion •TREATMENT Benzathine Penicillin & FOLLOW-UP G 2.4 million units IM x 1 Presumptive‡ Primary Syphilis§ : Tre at , Follow-up**, Report Alternative Regimens for Penicillin Allergic Non-Pregnant Patients: No efficacy not well established & not studied in HIV+; close follow-up essential: & Partner Management • Doxycycline 100 mg po bid x 2 weeks or Wait for serology results S M • 500 mg po qid x 2 weeks or • Ceftriaxone 1gm IM or IV qd x 10-14 d Crusted syphilitic ulcer, urethra Healing syphilitic ulcer

See CDC 2010 STD Treatment Guidelines: www.cdc.gov/std/treatment/2010/default.htm 2 Reactive & California STD Treatment Guidelines Grid: RPR/VDRL www.stdhivtraining.org/resource.php?id=15 ‡Primary Syphilis : § Reactive Tre at , Follow-up**, Report TP-PA/FTA-ABS ** Follow-Up To Assess Treatment Response & Partner Management Negative • 1-2 weeks & 1 month: clinical follow-up • 3, 6, 9, 12, 24 months: serologic follow-up for HIVinfected C M • 6, 12 months: serologic follow-up for HIV negative Negative • Repeat RPR or VDRL 2-4 weeks after • Treatment failure: failure of titer to decline fourfold within 6-12 months from titer first visit to rule out syphilis Syphilitic ulcer, perianal Syphilitic ulcer, tongue at time of treatment. • Consider ordering TP-PA or FTA-ABS • Repeat RPR or VDRL in 2-4 weeks if no other etiology identified. • Consider other etiologies (HSV) M Reprinted from Atlas of Sexually Transmitted Disease and AIDS, 2nd/ed, Morse, Holmes, Ballard, Figures 2.9, Photo2.12, 2.13, Credits 2.14, 2.17, Copyright 1996, with permission from Elsevier Science. S With permission from San If reactive than repeat TP-PA or FTA-ABS Francisco City Clinic. C Centers for Disease Control. and Prevention • If repeat TP-PA or FTA-ABS is negative then RPR/VDRL is biologic false positive • Consider other etiologies (HSV) see the online version of the Primary Syphilis Algorithm on *, †, ‡, §, ** see color coded boxes the clinical resources page of the CA STD/HIV PTC website: § • All syphilis cases or suspected cases must be reported to the local health 1. Also consider culture for if exposure in endemic areas or if lesion does not respond to syphilis treatment. http://www.stdhivtraining.org For additional copies, department within one working day of diagnosis 2. All patients with suspected syphilis should be tested for HIV infection & screened for other STDs. Repeat HIV testing of patients with • REPORTINGLocal health departments & PARTNER will assist inMANAGEMENT partner notification & management primary syphilis 3 months after the first HIV test, if the first test is negative. 3. If the patient is MSM (men who have sex with men) or has high risk sexual behavior (multiple partners, exchange of sex for money or drugs) The California STD/HIV Prevention Training Center thanks the • Contact Number at Local Health Department Medical Directors from the National Network of Prevention Training or clinical exam with classic features of a syphilitic ulcer then presumptive treatment is recommended. Also consider presumptive treatment California Centers, The California STD Controllers Association and the Division if patient follow-up is a concern. STD/HIV Prevention ofAcknowledgements STD Prevention of the Centers for Disease Control and Prevention Training Center for their assistance in preparing this document. Revised 4/2011 Evaluating Patients For Secondary Syphilis • Symptoms typically occur 3-6 weeks after primary stage (can overlap with primary); resolve in 2-10 weeks • 25% may have relapses of signs & symptoms in first year Clinical Presentations Of Secondary Syphilis • : most common feature (75-90%); can be macular, papular, squamous (scale), pustular (rare), vesicular (very rare) or combination; usually nonpruritic; may involve palms & soles (60%) * Sexual History, Risk Assessment (past year): Physical Exam • gender of partners • oral cavity Signs• Generalized & Symptoms Lymphadenopathy: of Secondary Syphilis (70-90%); inguinal, axillary & cervical sites most commonly affected SEXUAL• number of HISTORY,partners (new, anonymous,RISK ASSESSMENT serodiscordant & PHYSICAL• lymph nodes EXAM • Constitutional Symptoms: (50-80%); malaise, fever HIV status, exchange of sex for drugs or money) • skin • Mucous patches: (5-30%); flat gray-white patches in oral cavity & genital area • types of sexual exposure • palms & soles • Condyloma lata: (5-25%); moist, heaped, -like lesions in genital, peri-rectal & rectal areas, & oral cavity • recent STDs; HIV serostatus • neurologic • Alopecia: (10-15%); patchy hair loss, loss of lateral eyebrows • substance abuse • genitalia/pelvic Patient with new onset rash, atypical warty lesion or • Neurosyphilis: (<2%); visual loss, hearing loss, cranial nerve palsies • condom use • perianal other signs & symptoms of secondary syphilis History of syphilis prior syphilis (last serologic test & last treatment) * SEXUAL HISTORY, RISK ASSESSMENT & PHYSICAL EXAM

† RPR/VDRL† • ~100% sensitive in secondary syphilis DIAGNOSTIC WORK-UP • DIAGNOSTICTests must be quantified ISSUES to the highestIN SECONDARY titer & titer on the SYPHILIS day of treatment M S C must be used to assess treatment response • RPR or VDRL serology • Always use the same testing method (RPR or VDRL) in sequential testing; Macular & Papulosquamous Rash Subtle Macular Rash Condyloma lata cannot compare titer from the two tests • TP-PA or FTA-ABS to confirm reactive RPR or VDRL • Tests lack specificity (biologic false positive); all reactive tests need to be confirmed by a treponemal test for syphilis diagnosis • Prozone Reaction: false negative RPR or VDRL from excess antibody blocking the antigen-antibody reaction • ~1% of secondary syphilis cases Reactive Negative • Request lab to dilute the serum to at least 1/16 to rule out RPR/VDRL

M M M

Condyloma lata Papulosquamous Rash Papulosquamous Rash Negative Not Syphilis if TP-PA/FTA-ABS Prozone Reaction is ruled out ‡Treatment of Secondary Syphilis Recommended Regimen •TREATMENT Benzathine Penicillin & FOLLOW-UP G 2.4 million units IM x 1 Reactive Alternative Regimens for Penicillin Allergic Non-Pregnant Patients: 1 efficacy not well established & not studied in HIV+; close follow-up essential: Secondary‡ Syphilis : § Biologic False Positive: S M C • Doxycycline 100 mg po bid x 2 weeks or **, • Tetracycline 500 mg po qid x 2 weeks or Tre at , Follow-up Report Not Syphilis • Ceftriaxone 1gm IM or IV qd x 10-14 d & Partner Management Macular Rash Mucous Patches Alopecia of the rash of secondary syphilis includes: , , multiforme, , scabies, drug reaction ( e.g. from HAART ), primary HIV infection See CDC 2010 STD Treatment Guidelines: *, †, ‡, §,** see color coded boxes www.cdc.gov/std/treatment/2010/default.htm 1. All patients with suspected syphilis should be tested for HIV infection & screened & California STD Treatment Guidelines Grid: Differential Diagnosis www.stdhivtraining.org/resource.php?id=15&ret=clinical_resources for other STDs. Repeat HIV testing of patients with secondary syphilis 3 months after the first HIV test, if the first test is negative **Follow-Up To Assess Treatment Response • 1-2 weeks & 1 month: clinical follow-up • 3, 6, 9, 12, 24 months: serologic follow-up for HIVinfected • 6, 12 months: serologic follow-up for HIV negative • Treatment failure: failure of titer to decline fourfold within 6-12 months from titer at time of treatment see the online version of the Secondary Syphilis Algorithm on the clinical resources page of the CA STD/HIV PTC website: http://www.stdhivtraining.org S M M For additional copies, Drug Reaction Tinea Versicolor Generalized Scabies The California STD/HIV Prevention Training Center thanks the Medical Directors from the National Network of Prevention Training Centers, •§ All syphilis cases or suspected cases must be reported to the local health The California STD Controllers Association and the Division of STD PreventionAcknowledgements of the Centers for Disease Control and Prevention for their M department within one working day of diagnosis M Reprinted from Atlas of Sexually Transmitted Disease and AIDS, 2nd/ed, Morse, Holmes, Ballard, Figures 2.20, 2.23, 2.26, 2.33, • REPORTINGLocal health departments & PARTNER will assist inMANAGEMENT partner notification & management assistance in preparing this document. Revised 4/2011 Photo2.37, 2.43, Credits 2.45, 2.47, Copyright 1996, with permission from Elsevier Science. S With permission from San Francisco City Clinic. California C Centers for Disease Control and Prevention STD/HIV Prevention • Contact Number at Local Health Department Training Center