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Hello.
My name is Dr. Sharon Adler, and I'm going to be talking with you today about syphilis.
I'm going to be focusing in on staging for syphilis,
why staging is so important for every patient who's diagnosed with syphilis.
And I'll also talk about treatment,
sharing with you the current treatment recommendations as well as why a day of titer times are so important
and follow up.
So you have some idea as to which patients are most at risk for syphilis,
I'm going to share one epidemiology slide with you, and on this slide you can see primary
and secondary syphilis cases within California divided by gender from 1996 to 2009.
In the green are females.
The blue are male cases.
And then the red dotted line are men who have sex with men,
and that's for cases where we actually have information on gender of partners.
What you can see on this slide is the number of cases among females has really plateaued.
And in contrast, the number of cases among males has been on the rise starting in about 1996.
And now the vast majority of our cases of syphilis are among males,
with most of those males being men who have sex with men.
So we're thinking about syphilis,
men who have sex with men is a population where you have to be very concerned about syphilis
and have high suspicion in terms of looking for signs and symptoms of syphilis in those patients.
When we think about syphilis, syphilis can present the provider with numerous challenges,
and that's because there are variable clinical manifestations.
In addition there can be some grey areas in terms of its management.
However, there fundamentally can be thought of as three R's of syphilis.
The first R being Recognizing.
So to recognize the numerous clinical manifestations of syphilis and be on the alert for them,
particularly among patients like men who have sex with men who have epidemiologic risk for syphilis as well.
The second R is treatment. So treat with an appropriate regimen, a recommended regimen.
And, in addition, in many clinical settings providers do not actually have access to rapid tests.
So they don't have access to a dark field, they don't have access to a stat RPR,
so decisions about presumptive treatment
or impair treatment need to take place in patients who present with clinical manifestations consistent with
syphilis and/or who present at high risk for syphilis.
And then the third R is Reporting.
So every patient who's diagnosed with syphilis
or every patient who is a suspect case of syphilis needs to be reported to the local health department.
In California that reporting should take place within 24 hours, whether it be by phone, mail or fax.
Now I'm going to move on and talk about syphilis staging.
So why is syphilis staging so important?
It's important because staging is going to impact the patient treatment,
and it's also going to impact the partner management.
So the first sign in staging is to determine does that patient have any clinical manifestations?
Do they have any signs or symptoms consistent with syphilis?
Patients who have signs consistent with primary syphilis get staged as having primary syphilis.
Patients with signs and symptoms consistent with secondary, get staged as having secondary.
Now I'm going to share with you some pictures that demonstrate the numerous clinical manifestations of primary
syphilis.
So for primary syphilis, the lesions typically are a single, painless ulcer that usually has minimal exudate.
It's about one-and-a-half-to-two centimeters wide.
And usually there is induration associated with this ulcer.
However, patients don't present like the textbook says they're going to present,
so oftentimes patients can have multiple lesions, and these lesions can be painful,
so they could be painful if the patient has co-infection with another infection,
or they can be painful if they're secondarily infected by skin flora as well.
On this slide I'm showing you the ano-genital manifestations of primary syphilis.
However, syphilis can present at the site of inoculation,
so the ulcer -- chancre manifestation will occur wherever the initial inoculation takes place,
so if that's around the mouth, then the patient will have an ulcer or chancre around the mouth, or in the mouth,
and they can even be on a digit.
Patients presenting with these manifestations are staged as having primary.
Now we'll talk about secondary syphilis.
So secondary syphilis can manifest in numerous ways.
Rash is one of the most common manifestations of secondary syphilis.
And this rash, often early it is a macular rash that is kind of copper colored,
but it can manifest with numerous morphologic features, so the rash can be macular, papular, papulosquamous, anular,
lenticular, basically any morphologic feature can manifest for secondary syphilis.
The rash commonly is on the palms and the soles, maybe 60% to 80% of the time.
But people can have secondary syphilis and not have rash on the palms and soles as well.
In addition, patients often have generalized lymphadenopathy and they feel terrible.
They feel like they've got the flu.
They may have fevers.
They have body aches.
They've got a sore throat.
These are called constitutional symptoms, which are very common in secondary syphilis.
Somewhat less commonly,
patients with secondary syphilis can have other manifestations such as mucus patches in the mouth which are grey-white
thickened lesions.
They can have condylomata, which can mimic warts in the ano-genital area, so moist, wart-like lesions in skin folds
or in the ano-genital area.
And an alopecia is another fairly uncommon manifestation but can occur with secondary syphilis.
So that's patients presenting with symptoms.
If they have primary symptoms, they're staged as having primary.
Patients presenting with secondary symptoms are staged as having secondary.
Patients who have no symptoms or clinical manifestations of syphilis are then staged as having latent infection,
and these patients are usually picked up by a screening blood test, screening serologies,
that are reactive for syphilis.
I want to stress that before you make the diagnosis of latent syphilis,
that patient needs to undergo a very thorough physical exam to make sure they have no hidden manifestations of
syphilis, either primary or secondary syphilis.
So you need to do a oropharyngeal exam, a thorough skin exam.
You need to do an ano-genital exam that includes a speculum evaluation in a female because she could have a hidden
ulcer on the *** or on the *** and she may not be aware of it because these are painless usually.
And then anyone who is being staged as latent infection needs to undergo a very thorough neurologic exam as well.
Because neurosyphilis can actually manifest at any stage of syphilis.
Once a patient meets criteria for having latent syphilis,
and that's basically there's no clinical manifestations of syphilis on their physical exam
and they've been picked up by a serologic blood test, latent syphilis is then further divided into three stages.
Early latent, which is syphilis that has been acquired for less than one year, versus late latent
or latent of unknown duration.
Now the distinction between early latent syphilis and late latent
or latent of unknown duration is made for purposes of patient treatment.
The distinction between late latent or latent of unknown duration is made for purposes of partner management.
So what criteria is used to determine that a patient has actually been infected for less than one year?
We'll take a look here.
So there are specific criteria that are used.
So patients who have acquired the infection less than one year,
they can meet this criteria if in the past year they had a negative test, negative RPR,
or treponema test for syphilis and now they have a positive titer, then they can meet criteria for early latent syphilis.
In addition, patients who have had a known contact to an early case of syphilis or patients who have typical signs
or symptoms of early syphilis in the past year can also be staged as having early latent syphilis.
In addition, in the rare scenario where someone's only possible exposure was in the prior year,
again they can meet criteria for having early latent syphilis.
The final criteria listed here is in the scenario when someone has a fourfold rise in titers.
And this is in someone usually who was previously infected and then treated and now their titer has risen fourfold.
Now this might be a sign of re-infection.
It also could be possibly a sign of treatment failure.
And this needs to be determined on a case-by-case basis to find whether they actually are a patient who has early
latent disease or whether they possibly are someone with treatment failure.
Patients who do not meet any of these criteria for early latent disease are staged as late latent
or latent of unknown duration.
And why staging is so important is because the treatment
is determined by the specific stage that is assigned to that patient.
So here we have the current CDC 2010 STD treatment guidelines, syphilis treatment recommendations.
For patients who were staged with primary, secondary, or early latent disease, these patients,
one dose of benzathine penicillin G, 2.4 milliunits IM, is adequate therapy.
Patients who are staged as late latent or latent of unknown duration, they necessitate a longer duration of therapy,
and they should be treated with benzathine penicillin G, 7.2 milliunits total,
given as three doses of 2.4 milliunits IM each at one week intervals.
Very importantly for the provider, at the time the patient is receiving treatment,
the provider should take a look at the chart
and make sure that they've had a recent RPR VDRL titer because that is the titer that they're going to use to
assess whether the patient actually has an adequate response to therapy.
And if not, a day of treatment titer should be obtained.
And how about extra doses of benzathine penicillin G for patients who are staged with early syphilis?
So these are patients staged with primary, secondary, or early latent disease.
Current data basically demonstrate that these are not necessary,
that adequate therapy is the one dose of benzathine penicillin G for patients who are staged appropriately with early
syphilis, and giving additional doses of benzathine penicillin G or adding other antibiotics are not necessary,
they don't enhance efficacy, and this is regardless of the patient's *** status.
So now I'm going to move on and talk about a case scenario.
So here we have a 30-year-old male who presents to his primary provider with a new onset rash,
and the provider makes a presumptive diagnosis of a viral exanthema.
Luckily the provider also thinks about syphilis and gets an RPR titer at that very first visit on June sixth.
Because syphilis is thought to be low among the differential, no presumptive treatment is given on that first visit.
Four days later, the laboratory tests come back and it turns out the patient does have syphilis.
He has a reactive RPR of one to 16 and a confirmatory treponematasis as well.
So the provider tries to contact the patient, turns out the patient's out of the country, not available to come back.
A very common scenario.
It takes him over three weeks to get back in for treatment, so he comes back on June 30th and returns for treatment.
And luckily the provider astutely gets a day of treatment titer.
Now we'll take a look at the patient's follow-up titers to show you the importance of getting a day of treatment titer.
So for early syphilis,
the way to assess whether the patient has had adequate response to therapy is by demonstrating a fourfold drop in
titer at six to 12 months.
In this patient scenario, if the patient did not have a day of treatment titer,
what we would be looking at is a first visit titer of one to 16, a six-month follow up titer of one to 64,
which is a fourfold rise, and which would be very concerning and would probably necessitate evaluation,
possibly a lumbar puncture, definitely a repeat RPR test.
And then when we look at the 12-month follow up RPR titer,
you can see that it has been unchanged from that first visit,
so the titer is one to 16 at the first visit and one to 16 at the 12-month follow up.
And again, here, that would be concerning.
Luckily, this provider did get a day of treatment titer.
And what's demonstrated is in that three-week period where the patient was out of the country,
his titer rose dramatically.
So it went from one to 16 to one to 128.
And now, when we look at his six-month follow up and his 12-month follow up titers,
you can see he actually has had an appropriate response.
And that titer on June 30th of one to 128,
it dropped more than fourfold to a titer of one to 16 at his 12-month follow up.
So having a day of treatment titer is extremely important,
particularly in early syphilis when titers can rise dramatically,
and in this specific case scenario it demonstrates that without it,
this patient would have required further intervention.
So how good a job are our California providers doing in terms of getting a titer on or close to the day of treatment?
This pie chart is a case review of primary,
secondary syphilis cases that was done in 2007 from the California Department of Public Health STD Control Branch,
and what you can see highlighted in yellow is that 43% of the time there was not a titer within seven days,
so there's lots of room for improvement in terms of obtaining a titer close to
or on the day of treatment for all patients, particularly in early syphilis.
So to summarize for this presentation,
I hope to have emphasized that there are the three R's of syphilis which are fundamental management strategies.
First recognizing the numerous clinical manifestations of syphilis
and being on the alert for them among patients at risk, and within California that's men who have sex with men.
Treating all patients diagnosed with syphilis
and oftentimes having to give presumptive treatment for patients based on clinical manifestations.
And then the third R is Reporting all suspect
and diagnosed cases of syphilis to the local health department within 24 hours.
But beyond the three R's, there are other key management strategies that should take place.
First is staging.
So every patient should be assigned a stage,
and that stage is going to determine what their treatment is as well as how their partner is going to be managed.
Secondly, as I said, the treatment should be based on the stage, and for early syphilis,
one dose of benzathine penicillin G is adequate therapy for patients who are staged appropriately with early syphilis.
For providers,
recognizing that the day of treatment titer is very important because this is going to make their interpretation of
follow up titers more reliable.
And then finally, follow up is very important,
and patients need to do a good job of educating their patients about the importance of follow up.
The only way to determine whether they've actually had an adequate response to therapy is by the demonstration of a
fourfold drop in titers at their follow up visits. Thank you.