DATE:	June 21, 2010
TO:	Medical Providers
FROM:	Wendi Dick, MD, MSPH, Assistant Health Officer/STD Controller
ATTACHED:	Syphilis Alert Syphilis Guidance (files available 7/2/10)

Consider the Dx of syphilis, especially in Men who have Sex with Men and reproductive-age women. Syphilis is on the rise in San Joaquin County. Cases of the very infectious Primary/Secondary (°1/2°) stages have more than tripled recently, increasing from 7 in 2008 to 25 in 2009. The year 2010 could be our worst since 1997, with 13 cases reported already. Several nearby counties are also experiencing an increase.

Most sexual transmission occurs during the highly infectious 1°/2° stages via oral, vaginal, or anal sex. Much of the recent increase involves MSM (~85% of male cases), of whom nearly half are HIV co-infected. Female cases appeared this year, including a pregnant case. Few of the reported cases presented in the 1° stage, characterized by an ulcerated papule or ‘chancre’ that is usually painless and can easily go unnoticed. Most presented with a rash (2° stage). Several cases were diagnosed only after multiple evaluations.

Syphilis screening includes an RPR or EIA; confirm with 2nd test. All +/reactive RPRs need a titer.

Maternal-fetal transmission can occur at any stage; 1°/2° stages are much greater risk than Latent.ϒ The 1st prenatal visit should include syphilis serology screening (RPR or EIA). Women at higher risk for STDs should be re-screened at 28 weeks and at delivery. (ϒLatent syphilis = seropositive but no symptoms.)

Anyone seeking HIV or STD testing should also be screened for syphilis:

• Chancre-like lesions: Order RPR or EIA, and consider herpes culture. False-negative serology can occur early in the 1° stage; repeat negative tests in 2-4 weeks.
• New, unexplained rash and sex in the past year or unclear history: Order RPR or EIA (100% positive by the 2° stage). Syphilitic rash can erupt anywhere--palms/soles, trunk, limbs, etc. Other Sx can occur, such as flu-like illness, generalized lymphadenopathy, patchy hair loss, mucous patches, or condyloma lata.

Presumptive Tx is recommended for chancre-like lesions or unexplained rashes and sexual risk. This is particularly important when suspicion is high or follow-up is uncertain. Bicillin® L-A / benzathine PCN G Long-Acting is the recommended treatment and the only option if pregnant (desensitize if allergic).

Assess for HIV, neurologic signs/Sx, and Tx response. Treat partners to prevent further spread.

• Test for HIV. If a patient with ‘Early Syphilis’† is HIV−, repeat in 3-6 mos. (†1°, 2°, Early Latent, or titer >1:32)
• Neurosyphilis can develop at any stage; HIV+ elevates risk. CSF exam is needed for any neurologic signs/Sx, ie problems with vision/hearing/motor/sensory or cognition, cranial nerve palsies, meningitis.
• Monitor post-Tx titers: draw ‘baseline’ on Tx day #1 and recheck in 3-6 mos. Evaluate for possible Re-Infection or Tx Failure--signs/Sx persist or recur, titers rise 4-fold (ie 1:16→1:64), or do not decline.
• EIA/TPPA stays (+) for life. RPR becomes (−), or may persist at a low titer if treated at a later stage.
• Presumptively treat all recent (3 mos) partners of Early Syphilis cases--“Treat & Screen” on the same day.

Counsel--avoid casual sex especially with drugs/ETOH, limit partners, no condoms = no sex, get tested.

Report all syphilis within 1 work day to PHS. We investigate transmissible cases and contacts, and maintain files of all reported cases. Please call us at 468-3845 / 3820 to confirm history of prior treatment or with any questions. After hours, medical providers may reach PHS via the SJGH operator at 468-6000.

Need a Syphilis Update? Please call (209) 468-3845 / 3820 to request a medical presentation for your site.