Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 6, 2007 17:50

Syphilis 1397

■Clinical manifestations, serologic tests, and response to therapy may

be atypical in HIV-infected patients

■Indications for CSF evaluation

➣Neurologic or ophthalmologic signs or symptoms

➣Evidence of tertiary disease (gummas, cardiovascular)

➣Early syphilis treatment failure

➣HIV infection with late latent (>1 yr) or disease of unknown dura-

tion

■Some experts recommend CSF examination in all HIV-infected

patients

■Report case to local public health authorities and refer sexual part-

ners for evaluation and treatment

specific therapy

Indications

■Sexual partner of infected contact within past 3 months

■Positive darkfield examination or direct fluorescent antibody test

■Positive serologic tests:

➣Newly positive non-treponemal and/or treponemal test

➣Four-fold increase in non-treponemal serologic titer

■Neurosyphilis: no single test is diagnostic

➣Positive CSF VDRL

➣>5 WBCs/mm3 in CSF

➣Elevated protein

Treatment Options

Primary, Secondary, and Early Latent Syphilis and Epidemiologic treat-

ment

■Benzathine penicillin (PCN) IM in single dose

■PCN allergic: Doxycycline orally OR Tetracycline orally

Late Latent Syphilis (>1 year duration) and Tertiary (gumma, cardio-

vascular)

■Benzathine PCN IM weekly× 3

■PCN allergic (consider CSF examination before using alternative

drugs): Doxycycline orally OR Tetracycline

Neurosyphilis

■Aqueous crystalline PCN G

■OR (for compliant patients only) Procaine PCN IM daily, for 10–14

days PLUS Probenecid orally for 10–14 days

■PCN allergic: skin test and desensitize to PCN