Guidelines 2016 – Syphilis
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
Syphilis is a sexually transmitted, systemic disease characterized by periods of active florid manifestations and periods of symptomless latency. It can affect any tissue or vascular organ of the body and can be passed from mother to fetus.
II. ETIOLOGY
A. The causative organism is a motile spirochete, T. pallidum.
B. Incubation period: 10 to 90 days, with an average of 21 days
III. HISTORY
A. What the patient may present with
1. Primary symptoms
a. Painless lesion (chancre) at site of entry of T. pallidum. Chancre appears on average about 3 weeks after sexual contact and heals in 3 to 6 weeks with a small inoculum. This incubation period may be as long as 90 days. Sites include the vulva, labia, four- chette, clitoris, cervix, nipple, lip, roof of mouth, tonsils, bite area, finger, urethra, rectum, and smooth, firm borders of an ulcer.
b. Enlarged inguinal or regional nodes; trochlear
2. Secondary symptoms that may or may not occur in untreated patients within 4 to 10 weeks of resolution of primary symptoms
a. Generalized symmetrical papillosquamous eruption of palms, soles, or mucous membrane (condylomata lata)
b. Alopecia; may have a moth-eaten look
c. Loss of lateral one third of eyebrow
d. Generalized nontender lymphadenopathy with firm, rubbery feel
e. Symptoms of upper respiratory tract infection
316 VAGINAL CONDITIONS
f. Low-grade fever
g. Malaise, anorexia, and arthralgia
h. Mild hepatitis, splenomegaly, or nephrotic syndrome in about 10% of cases
i. Mucous patches on tongue, under foreskin, and in intertrigi- nous areas
3. Latent stage: No clinical symptoms, although 25% may have recurrence of cutaneous lesion; however, patients demonstrate serologic evidence.
a. Early latency: infection within the preceding year
b. Late latency: over a year from date of initial infection. Patients may remain in latent stage for remainder of their lives; however, one third will develop the tertiary form of disease.
c. Tertiary stage: Osseous or cutaneous structures; cardiovas- cular system or nervous system becomes involved; most common developments are cardiovascular syphilis and neurosyphilis
d. Neurosyphilis (exceedingly uncommon today) can occur at any stage from 1 to 30 or more years after original infection.
B. Additional information to be considered
1. Sexual preference
2. Current sexual activity
3. Last sexual contact
4. Birth control method(s)
5. History of known contacts
6. History of previous STI
7. History of recurrent infectious illness (e.g., mononucleosis)
8. History of fever, malaise, arthralgia, or rash of unknown etiology
9. History of cognitive dysfunction, sensory deficits, other neuro- logic symptoms
10. Current medical therapy
11. Risk for HIV exposure
IV. PHYSICAL EXAMINATION
A. Vital signs
1. Temperature
2. Blood pressure
3. Pulse
B. General examination of skin
1. Alopecia
2. Rash, including soles of feet, palms, condyloma lata
C. Pharyngeal examination
D. Examine for enlarged inguinal nodes
E. External examination of genitalia; vulvar lesions; chancre at point of inoculation
SYPHILIS 317
F. Internal examination (speculum)
1. Inspection of vaginal walls for lesions
2. Inspection of cervix for lesions
3. Inspection of discharge
G. Bimanual examination
H. Neurologic examination per history and clinical findings
V. LABORATORY EXAMINATION
A. Nontreponemal: Venereal Disease Research Laboratory (VDRL) and rapid plasma reagin (RPR)—these are nonspecific serum tests—detect cross-reaction of antibody to syphilis with cardiolipin. Reported as reactive or nonreactive. Reactive test is reported by a quantitative titer, and reactive tests should be confirmed with treponemal testing. Use of only one type of serologic test is insufficient for diagnosis.
1. Biological false-positives occur with cardiolipin antigens some- times present in drug abuse and in such diseases and conditions as
a. Lupus erythematosus
b. Mononucleosis
c. Malaria
d. Leprosy
e. Viral pneumonia
f. After smallpox vaccinations or other recent vaccinations
g. HIV
h. Narcotic addiction
i. Arthritis
j. Scleroderma
k. Tuberculosis
l. Chronic fatigue syndrome
m. Pregnancy
B. Specific serum treponemal antibody tests (correlate poorly with disease activity; persons who have a reactive test will have it for life unless diagnosis and treatment are very early)
1. Fluorescent treponemal antibody-absorption (FTA-ABS) test
2. Treponema pallidum particle agglutination (TP-PA)
C. GC culture
D. Chlamydia test
E. Biopsy of the lesion
F. Dark-field microscopy exam (rarely available in freestanding clinics or offices)—most useful for males
G. Consider HIV testing; testing for hepatitis B and C
VI. DIFFERENTIAL DIAGNOSIS
A. Herpes simplex
B. Condylomata acuminata
C. Granuloma inguinale
D. Chancroid
318 VAGINAL CONDITIONS
E. Lymphogranuloma venereum
F. Carcinoma
G. Pyoderma
VII. TREATMENT
With physician consult in some settings
A. Medication (for primary and secondary syphilis)
1. Benzathine penicillin G (BiCillin) 2.4 million units im single dose immediately. Caution regarding Jarisch–Herxheimer reaction: In 50% of cases, 6 to 12 hours after injection, the patient develops high fever, malaise, and exacerbation of symptoms lasting 24 hours. (This is a sign that the spirochete is breaking down.) Occurs most frequently among patients with early syphilis.
2. For penicillin allergy: doxycycline 100 mg orally twice a day for 14 days or tetracycline 500 mg orally four times a day for 14 days
B. For early latent syphilis (< 1 year)
Benzathine penicillin G, 2.4 million units im in a single dose
C. For late latent syphilis or unknown duration
Benzathine penicillin G, 7.2 million units total, in three doses of
2.4 million units im each at 1-week intervals
D. For late syphilis or unknown duration
Benzathine penicillin G, 7.2 million units total, in three doses of
2.4 million units im each at 1-week intervals
E. In pregnancy
1. Treat with penicillin regimen appropriate for stage of syphilis
2. Hospitalize pregnant patients with history of penicillin allergies to undergo skin testing. If testing is positive, they should be desensitized and treated with penicillin (see CDC guidelines, 2015).
F. General measures
1. Support, especially in regard to possible Jarisch–Herxheimer reaction
2. Stress the importance of completing all medication
3. Partner should be treated concurrently; treat all contacts exposed within 90 days of diagnosis of primary, secondary, or early latent syphilis presumptively; persons exposed more than 90 days before diagnosis of primary, secondary, or early latent syphilis in a sex partner should be treated presumptively if serologic test results are not immediately available and follow-up is uncertain.
VIII. COMPLICATIONS
A. Progression of disease to tertiary stage
B. One hundred percent transmission to fetus with primary and secondary in pregnancy; 50% fetal mortality and 50% congenital syphilis
1. Early latent: 80% fetal infection (20% premature, 20% fetal death, 40% congenital syphilis)
2. Late latent: 30% fetal transmission, 11% fetal death
IX. CONSULTATION/REFERRAL
Positive diagnosis of disease
X. FOLLOW-UP
TRICHOMONIASIS 319
Quantitative serology tests for primary and secondary syphilis (nontreponemal serologic) should be obtained at 6 and 12 months (falling titer should be demonstrated if treatment is adequate—at least a fourfold drop by 6 months using the same test). If repeat titer does not decrease, patient should be followed with titers or re-treated. For persons with persistent signs and symptoms, symptoms that recur, or a fourfold increase in nontreponemal test titer, re-treat and reevaluate for HIV. For latent syphilis, repeat testing at 6, 12, and 24 months.
See Appendix I and Bibliographies.
Websites: www.cdc.gov/std/treatment/2015; www.cdc.gov/mmwr/pdf/rr/ rr5912.pdf