Syphilis: A review

Syphilis: A review

SYPHILIS: A REVIEW REBECCA KOBOS, MD OCTOBER 24, 2019

DISCLOSURES No disclosures Gratitude and thanks to AC and NYS DOH clinical and support staff! CASE 1 19 yo female presents for ST and fever. PMH: treated for syphilis

two years ago. got a few shots. No follow-up since. No records to review. PSH: none. Meds: none. LMP regular. On OCP. No missed pills. NKDA In addition to eval for strep, mono what else should we screen for? CASE 2

25 yo male with oral lesion. PMH/PSH: None. Meds: None. MSM. No h/o STI. No recent screening DDX: HSV, aphthous ulcer What labs might you order? Reverse Algorithm WHAT IS SYPHILIS?

Syphilis is a bacterial infection Caused by Treponema pallidum Transmitted person to person From exposure through vaginal, anal, or oral sex Or vertically from mother to unborn child during pregnancy

SYPHILIS (CDC IMAGE) Spirochete bacteria

Helically coiled microorganism usually 6 15 m long and 0.1 0.2 m wide Using light microscopy treponemes are visible only by using dark field

illumination Dark field illumination SYPHILIS The Great Imitator He who knows syphilis, knows medicine. Sir William Osler, First

Chief of Johns Hopkins, influential in creating medical residencies Tuskegee Study. 1932-1972. US Public Health Service conducted observational studies on African American men in Alabama. Unethical as researchers failed to communicate to patients their diagnosis, failed to offer treatment to patients, even when Penicillin available

SCREENING. WHO SHOULD WE SCREEN? All patients with signs/symptoms of syphilis Sex partners of confirmed cases PREGNANT WOMEN. Screening at 1st prenatal visit, and again at beginning of 3rd trimester and at

delivery if at risk* MSM, annually or more often if at risk* HIV positive patients should be tested annually All sexually active individuals * CDC risk factors: history of syphilis, incarceration, drug use, multiple or concurrent partners, women who live in high prevalence areas In 2017, in Albany County, 30 % of all syphilis cases were reported by primary care providers

STAGES OF SYPHILIS STAGING IS BASED ON HISTORY, PHYSICAL EXAM AND SEROLOGY STAGING GUIDES TREATMENT AND FOLLOW-UP Primary * symptomatic, contagious

Secondary *symptomatic, contagious Early, Non-Primary/Non-Secondary *no clinical symptoms, exposure within the last 12 months, +/- contagious Late or Unknown duration *no clinical symptoms, >12 months Tertiary *end organ disease STAGING NO LONGER USES THE TERM

LATENT Changes in reporting because certain clinical s/s ie: Neuro, Ocular or Otic can occur at any stage in the disease Clinical advisory from CDC 2016 Between December 2014 and March 2015, 12 cases of ocular syphilis were reported from two major cities, San

Francisco and Seattle. Subsequent case finding indicated more than 200 cases reported over the past 2 years from 20 states. Ocular syphilis can involve almost any eye structure, but posterior uveitis and panuveitis are the most common. Additional manifestations may include anterior uveitis, optic neuropathy, retinal vasculitis and interstitial keratitis. Ocular syphilis may lead to decreased visual acuity including permanent blindness. Ocular syphilis can be associated with neurosyphilis. Both ocular syphilis and neurosyphilis can occur at any stage of syphilis, including primary and secondary syphilis.

PRIMARY PATIENTS WITH SYMPTOMS AND CONFIRMED SEROLOGY Primary: 10-90 days after exposure. chancre: firm, round, painless, at exposure site usually resolves in 3+ weeks with or without treatment

progresses to secondary syphilis unless treated PRIMARY SYPHILIS 10-90d after exposure Painless chancre at exposure

site Lasts 3 weeks Will resolve without treatment Contagious Progresses to secondary syphilis unless treated

PRIMARY SYPHILIS, Chancre (CDC ONLINE IMAGES) SECONDARY

PATIENTS WITH SYMPTOMS AND CONFIRMED SEROLOGY Secondary: Symptoms usually presents 3-6 weeks after the chancre appears, and may persist for weeks to months Rash LAD, malaise mucous patches

condyloma lata alopecia Fever, swollen glands, ST Hepatitis Resolves regardless of treatment Progresses to LATE stage if not treated

Condyloma Lata: usually in warm moist areas: mouth, underarm, groin. Soft warty flat velvet STAGING,

CONTINUED Patients without clinical apparent disease and confirmed serology Early non Primary non Secondary = Early. exposure history within one year Unknown or Late = Late. > 12 months/unknown duration

Tertiary. Years later. End organ damage; cardiac (thoracic aneurysm), CNS disease, tabes dorsalis SEROLOGY FOR DIAGNOSIS Need BOTH: A reactive TREPONEMAL (AB) test AND

A reactive NONTREPONEMAL (RPR) test Non treponemal (RPR) test can be seen with HIV, autoimmune conditions, endocarditis, pregnancy, etc; therefore can be a False positive Non treponemal (RPR) test usually declines after treatment Therefore, after treatment, follow the RPR Treponemal Antibody test should stay elevated even after treatment

TREPONEMAL SPECIFIC ANTIBODY TESTS FTA: fluorescent treponemal antibody EIA: enzyme immunoassays CIA: Chemiluminescence immunoassays TPPA: treponemal passive particle agglutination WHAT LABS TO ORDER?

60/ NO.5 Reverse algorithm Start with EIA (AB test) If NON REACTIVE no syphilis diagnosis, consider check FTA if early If REACTIVE check RPR (most labs reflex to

this) If RPR REACTIVE = + SYPHILIS If RPR NON REACTIVE, consider TPPA. IF TPPA REACTIVE = + Syphilis IF TPPA NONREACTIVE, no syphilis diagnosis. All discordant specimens (EIA +/RPR need

a confirmatory treponemal test, ie: TPPA for diagnosis MMWR/ FEBRUARY 11, 2011/ VOL. HOW LONG AFTER EXPOSURE DO CLINICAL SYMPTOMS OCCUR? .

ESTIMATION 10-90 days HOW LONG AFTER CLINICAL SYMPTOMS WILL SEROLOGY BE POSITIVE? .. ESTIMATION FTA : 5 days

EIA: 7-9 days RPR: 12 days TPPA: 15-16 days TIMELINE Exposure 3-6 weeks chancre, Primary

3-6 months ITIS, Secondary 12 months Early, Non-Primary, Non-Secondary > 12 months, Late or Unknown duration DIAGNOSIS Two tests to make the diagnosis

EIA (positive in about 1 week after symptoms) AND RPR (positive in about 2 weeks after symptoms) If RPR negative, consider TPPA (positive in about 2.5 weeks after symptoms) TREATMENT

Recommended treatment for Adults with Primary or Secondary Benzathine PCN G 2.4million units IM in a single dose Recommended treatment for Adults with Early, Non-Primary/Non-Secondary Benzathine PCN G 2.4million units IM in a single dose Recommended treatment for Adults with Late or Unknown duration Benzathine PCN G 2.4million units IM x THREE doses, one week apart

SPECIAL CONSIDERATIONS FOR TREATMENT Penicillin Allergy. Limited data to support other alternatives. Doxy 100 BID x 14 days for primary and secondary and 28d for Early NP-NS. Consider DESENSITIZE Parental Penicillin G is the ONLY therapy with documented efficacy for syphilis in pregnancy. DESENSITIZE Jarish Herxheimer Reaction: acute febrile reaction with headache, myalgia, fever

within first 24 hours. This occurs most frequently among patients with early syphilis possibly due to higher bacterial burden. Treated with antipyretics. In pregnancy this reaction may induce labor and/or fetal distress. MANAGEMENT OF SEX PARTNERS Transmission likely only occurs when lesions are present Lesions are uncommon after the first year of infection

Treat contacts of patients with primary, secondary or non-primary/nonsecondary within 90 days preceding the diagnosis, even if serology negative Long term partners of persons with late or unknown syphilis should be evaluated clinically and serologically for syphilis and treated based on findings DIS for sex partners of persons with syphilis considered at risk for infection, within: 3 months for Primary Syphilis 6 months for secondary syphilis

1 year for early non-primary, non-secondary FOLLOW-UP All patients diagnosed with syphilis should be tested for HIV For Primary and Secondary Syphilis: exam and serology at 6 months and 12 months. RPR titer should be decline fourfold within 6-12 months after treatment. If it doesnt guidelines are unclear on next step at minimum:

reevaluate clinical, serology and HIV status and consider re-treatment For Early non primary/non-secondary and late or unknown: exam and serology at 6, 12, and 24 months, along with clinical exam and reevaluation for HIV PCN is IM Q7 days x 3 doses. IF dose is missed, 10-14 days between doses might be acceptable for adults BUT NOT ACCEPTABLE For Pregnant women. RESTART the therapy if a pregnant women misses any dose.

RESOURCES CDC 2015 Sexually Transmitted Disease Treatment Guideline CDC website Syphilis- pocket guide Clinical Education Initiative (CEI) STD Center of Excellence Webinars

Medical consultation Your local County Health Department CASE 1 19 yo female presents for ST and fever. PMH: treated for syphilis two years ago. got a few shots. No follow-up since. No records to review.

PSH: none. Meds: none. LMP regular. On OCP. No missed pills. NKDA In addition to eval for strep, mono what else should we screen for? RPR HIV Obtain history of treatment from NYS DOH. Call local county DOH for help contacting the state

CASE 2 25 yo male with oral lesion. PMH/PSH: None. Meds: None. MSM. No h/o STI. No recent screening Reverse Algorithm screening CASES

25 yo male with oral lesion. PMH/PSH: None. Meds: None. MSM. No h/o STI. No recent screening Reverse Algorithm screening. TPPA and RPR are POSITIVE Stage? PRIMARY Treatment?

PCN G 2.4 mu IM x one Follow-up? HIV test. Recheck at 6months, 12 months Partners? Recommend all partners in last 90 days be evaluated and treated for primary syphilis THANK YOU!

Rebecca Kobos MD [email protected] EPT Expedited Partner Therapy to treat persons exposed to Chlamydia

Expedited Partner Therapy to treat persons exposed to Chlamydia NYSDOH Position Statement Chlamydia is a leading cause of pelvic inflammatory disease (PID), ectopic pregnancy, and infertility. People with untreated chlamydia may also be at increased risk for acquiring or transmitting HIV. Many people experience multiple episodes of chlamydia re-infection

soon after treatment, often due to lack of adequate treatment in their sexual partner(s). To prevent reinfection, minimize complications in individuals, and reduce transmission in the community, partners of patients with chlamydia must be provided timely and appropriate antibiotic treatment. Chlamydia is the most commonly reported communicable disease in the state, with over 110,000 diagnoses each year. Individualized public health follow-up for every case is impractical for most areas.

Expedited Partner Therapy (EPT) is the clinical practice of providing individuals with chlamydia medication or a prescription to deliver to their sexual partner(s) as presumptive treatment for chlamydia, without completing a clinical assessment of those partners. Randomized controlled trials have found that this strategy decreases rates of chlamydia reinfection among index patients and increases the proportion of sex partner(s) reported to be treated for chlamydia. , The Centers for Disease Control and Prevention, along with several national professional organizations, recommend EPT as

an effective and practical strategy for treating the sex partners of people with chlamydia. The New York State Department of Health (NYSDOH) strongly encourages providers to utilize EPT as a strategy to treat the sex partner(s) of persons diagnosed with chlamydia. EPT for chlamydia is authorized under New York Codes, Rules, and Regulations (NYCRR) section 23.5, of Title 10, and Section 2312 of NYS Public Health Law. , Health care providers or pharmacists who administer

EPT in accordance with this law are not subject to civil or criminal liability and will not be deemed to have engaged in professional misconduct as a result of this strategy. EPT should not be provided for any partner(s) when the index patient with chlamydia is co-infected with gonorrhea, syphilis, and/or HIV. Treatment for chlamydia alone is not adequate to treat these other infections. EPT may not be clinically appropriate for every patient. For example, EPT is not recommended for gay, bisexual, and other men who have sex with men due to the lack of study data on EPTs effectiveness in this

population and the risk of STI/HIV co-infection among partners. EPT medication may be provided directly to the index patient to deliver to their sex partner(s). This approach is preferred to a written prescription because prescriptions may introduce barriers to accessing EPT such as transportation, cost, and/or confidentiality. Providing medication directly to the index patient may also be more convenient for providers. EPT prescriptions are currently waived from the NYS electronic prescription (eprescribe) mandate. A blanket waiver letter of the electronic prescribing

requirements is available As stated in NYCRR 23.5,8 health education materials must be distributed when providing EPT (medication or prescription). EPT health education materials may be ordered from NYSDOH The New York City Department of Health and Mental Hygiene produces EPTrelated health education materials Severe adverse reactions such as anaphylaxis are extremely rare with azithromycin. Milder side effects which may impact the success of treatment,

including nausea and vomiting, occur in fewer than five percent of patients.

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