Later, Jack’s partner is assessed by you. He receives the same treatment as Jack, and all his relevant screening tests are negative.
Your preceptor reminds you that clinicians play a vital role in the prevention of STIs by discussing risk reduction and safe sexual practices with the patients. You take the time to educate Jack’s partner about behaviors that increase exposure to STIs such as engaging in unprotected sexual activities. You discuss proper condom use and give him some online resources about healthy sexual practice (https://smartsexresource.com).
You explain to Jack that STI screening should be done every 12 months with low-risk sex including oral sex, anal sex where condoms are used and sex with a regular partner of known status. Otherwise, he should be tested every 3 months if he involves high risk sex including anal sex without a condom with partners whose status is different or unknown to the patient. You reassure that Jack and his partner are always welcomed to come in anytime if they have any concerns or questions.
On the way-out Jack says to you, “I felt very comfortable and welcomed in your clinic, thanks for providing a safe and nonjudgmental space for us”. He books an appointment in advance for post-treatment serologic testing to assess the treatment response for syphilis in 6 months. Treatment response is assessed clinically and serologically through nontreponemal tests and based on CDC recommendations should be done at 6 and 12 months. An appropriate serological response is a fourfold or greater decrease in nontreponemal tests.
Objectives:
Describe the cutaneous presentations of primary and secondary syphilis.
Describe the steps involved in the diagnosis of syphilis with serology and learn how to interpret the test results.
List the treatment options for primary and secondary syphilis including patients with penicillin allergy.
Understand the public health implication of syphilis, the track-back period, and the treatment for sexual contact.
Appreciate the social determinants of health in taking care of patients with syphilis.
Take Home Messages
Primary syphilis often presents as a chancre that is a single painless, indurated, well-circumscribed ulcer.
MSM are at increased risk of syphilis, and there is a high rate of co-infection of HIV with syphilis in MSM.
Diagnosis of syphilis (“syphilis serology”) involves three steps: Enzyme Immunoassay (EIA), Treponema Pallidum Particle Agglutination (TPPA), and Rapid Plasma Reagin (RPR).
Syphilis is of a public health importance in Canada due to the increase in the number of cases since 2014, and it is a reportable case to local public health authorities in all provinces and territories.
The track-back period for primary syphilis is 3 months, and for secondary syphilis is 6 months.
Penicillin G benzathine 2.4 million units IM one dose is the treatment of choice for primary and secondary syphilis, as well as sexual/blood contacts within the track-back period.
Secondary syphilis is a great mimicker and can produce a wide variety of signs and symptoms including the mucocutaneous lesions with or without systemic signs and symptoms.
Acknowledgement:
We would like to thank Dr. Carolyn Montgomery for reviewing this case and providing the team with valuable feedback! Dr. Carolyn Montgomery works at the Provincial STI/HIV Clinic of the British Columbia Centre for Disease Control (BCCDC). She is also one of the authors for the British Columbia Treatment Guidelines for Sexually Transmitted Infections.
References:
Forrestel AK, Kovarik CL, Katz KA. Sexually acquired syphilis: Historical aspects, microbiology, epidemiology, and clinical manifestations. J of Am Acad Dermatol. 2020;82(1):1–14.
Forrestel AK, Kovarik CL, Katz KA. Sexually acquired syphilis: Laboratory diagnosis, management, and prevention. J Am Acad Dermatol. 2020 Jan 1;82(1):17–28.
Tuddenham S, Ghanem KG. Approach to the patient with genital ulcer [Internet]. UpToDate. 2020 [cited 2020Dec22]. Available from: https://www.uptodate.com/contents/approach-to-the-patient-with-genital-ulcers
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Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: Granuloma Inguinale (Donovanosis) [Internet]; 2015 [cited 2020Dec22]. Available from: https://www.cdc.gov/std/tg2015/donovanosis.htm
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Hicks CB, Clement M. Syphilis: Screening and diagnostic testing [Internet]. UpToDate. 2019 [cited 2020Nov12]. Available from: https://www.uptodate.com/contents/syphilis-screening-and-diagnostic-testing?search=syphilis
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