Syphilis Testing and Management

Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice ProvidersGuest: Alex Yoby, PharmacistCME Credit Info:Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSYCME credit is available for up to 3 years after the stated release dateContact [email protected] if you have any questions about claiming credit.CDC’s Sexually Transmitted Infections (STI) TreatmentGuidelines, 2021Notable updates:These guidelines discuss 1) updated recommendations fortreatment of Neisseria gonorrhoeae, Chlamydia trachomatis, andTrichomonas vaginalis; 2) addition of metronidazole to the recommendedtreatment regimen for pelvic inflammatory disease; 3) alternative treatmentoptions for bacterial vaginosis; 4) management of Mycoplasma genitalium;5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testingamong pregnant women; 7) one-time testing for hepatitis C infection; 8)evaluation of men who have sex with men after sexual assault; and 9) two-steptesting for serologic diagnosis of genital herpes simplex virusSyphilis LoreIt is postulated that syphilis came to Europe in the 1490s when Columbusarrived in Italy from America. After Italy surrendered to the invading Frenchin 1495, this new disease rapidly spread across Europe. The name"syphilis" comes from the work of Girolamo Fracastoro, a noted poetand physician in Verona, Italy. In 1530, he wrote about a shepherd namedSyphilus who angered Apollo, causing the god to curse the entire populationwith the affliction that we now know as syphilisT. pallidumSyphilis is a systemic, bacterial infection caused byTreponema pallidum.  Treponema are thin,Gram-negative, slowly metabolizing spirochetal bacterium, requiring an averageof 30 hours to multiply. It is microaerophilic and cannot grow on standardculture media. Treponema pallidum’s outer membrane lacks lipopolysaccharidesand has few surface-exposed unique proteins, making it difficult for the immunesystem to fight the infection. Because of this characteristic, Tpallidum is labeled as a stealth pathogen. T. pallidum is theonly Treponema species that causes sexually transmitted disease.Syphilis is characterized by a wide range of variableclinical symptoms that can resemble other diseases, which make it difficult todiagnose without a test, therefore, it is often referred to as “The GreatImitator”. The infection progresses through multiple stages (primary,secondary, latent, and tertiary) and can affect virtually every organ system inthe body, even many years or even decades after the original infection.Infected people are contagious during the primary and secondary stages ofsyphilis.Stages of syphilisPrimary syphilis: Primary syphilis classicallypresents as a single painless ulcer or chancre at the site of infection but canalso present with multiple, atypical, or painful lesions. A chancre is definedas a firm, round, painless ulcer at the site of entry of an infecting organism.Chancres appear 10 to 90 days (median of 21 to 25 days) after exposure to theinfecting organism. While the chancre represents the initial local reaction tothe infection, the bacteria quickly become widely disseminated in the body,including the cerebrospinal fluid, even without any additional immediatesymptoms. Up to 70% of early syphilis patients will demonstrate cerebrospinalfluid (CSF) changes consistent with neurosyphilis, and 30% will have directevidence of T pallidum.  Despite this occurrence, very few will developclinical neurosyphilis. Secondary syphilis: A diffuse and extensivemaculopapular rash that includes the palms of the hands and the soles of thefeet, as well as oral lesions in the mouth, are the characteristic cutaneousmanifestations of secondary syphilis. Symptoms typically appear 2 to 8 weeksafter the disappearance of the primary chancre and have multiple systemicmanifestations that can involve any system or body part. The T pallidum multiplyand spread rapidly, causing fevers, myalgias, headaches, anorexia, sore throat,weight loss, joint pain, malaise, and particularly, the cutaneousmanifestations characteristic of secondary syphilis. Enlarged lymph nodesare common in this stage and are usually described as firm, rubbery, and withonly minimal tenderness. The lesions of secondary syphilis generally resolvewithin a few weeks, even without treatment, but will relapse in 25% ofuntreated patients, usually within 12 months. After that, without treatment,the disease enters the latent stage, and about 33% of patients will eventuallydevelop tertiary syphilis.Tertiary syphilis: Late symptomatic disease that canmanifest months, years, or even decades after the initial infection ascardiovascular syphilis (aortic aneurysm, aortic valvulopathy), neurosyphilis(meningitis, hemiplegia, stroke, aphasia, seizures, spinal neuroarthropathy,tabes dorsalis, syphilitic paresis), or gummatous syphilis (infiltration of anyorgan and its subsequent destruction).Latent syphilis: Latent syphilis is defined assyphilis characterized by seroreactivity without other evidence of primary,secondary, or tertiary disease. Latent infections (i.e., those lacking clinicalmanifestations) are detected by serologic testing. Latent syphilis acquiredwithin the preceding year is referred to as early latent syphilis; all othercases of latent syphilis are classified as late latent syphilis or latentsyphilis of unknown duration. Latent syphilis is not transmitted sexuallyNeurosyphilis: T. pallidum can infect the CNS, whichcan occur at any stage of syphilis and result in neurosyphilis. Earlyneurologic clinical manifestations or syphilitic meningitis (e.g., cranialnerve dysfunction, meningitis, meningovascular syphilis, stroke, and acutealtered mental status) are usually present within the first few months or yearsof infection. Late neurologic manifestations (e.g., tabes dorsalis and generalparesis) occur 10 to >30 years after infection.Congenital syphilis: Congenital syphilis results fromtransplacental transmission or contact with infectious lesions during birth andcan be acquired at any stage, often causing stillbirth or neonatalcongenital infections. Without treatment, up to 40% of women with syphilis willhave stillborn births, and many more will have premature labor orlow-birth-weight babies. Effective prevention and detection of congenital syphilisdepends on identifying syphilis among pregnant women and, therefore, on theroutine serologic screening of pregnant women during the first prenatal visitand at 28 weeks’ gestation and at delivery for women who live in communitieswith high rates of syphilis, women with HIV infection, or those who are atincreased risk for syphilis acquisition. Certain states have recommendedscreening three times during pregnancy for all women; clinicians should screenaccording to their state’s guidelines.EpidemiologyPer the CDC, a syphilisepidemic is occurring in the United States, with sustained increases in primaryand secondary syphilis from 5,979 cases reported in 2000 to 133,945 casesreported in 2020, a 2,140% increaseThe rate of reported congenital syphilis in the UnitedStates has increased dramatically since 2012. About 53 percent of congenital syphilis is reported fromsouthern states, according to data from the U.S. Centers for Disease Controland Prevention.3,761 cases ofcongenital syphilis in the United States were reported to CDC in 2022.including 231(6%) stillbirths and 51(1%) infant deaths. 88% of cases ofcongenital syphilis in 2022 were directly impacted by the lack of timelytesting and adequate treatment during pregnancy.·        MISSISSIPPI: In 2022, Mississippi ranked 5th inreported rates of primary and secondary syphilis with a rate of 31.1 per100,000 individuals (the rate was 28.1 per 100,000 individuals in 2021).Mississippi also ranked 6th in reported rates of congenital syphilis with arate of 207.6 per 100,000 live births (the rate was 182.0 per 100,000 livebirths in 2021).·        ARKANSAS: In 2017, only 27 pregnant women withreported...