Clinical Manual for Management of the HIV-Infected ... - myCME.com

Syphilis
Background
Syphilis is a sexually transmitted infection (STI) caused
by the spirochete Treponema pallidum. It is a complex
disease with protean variations that can mimic many
common infections or illnesses. HIV infection may alter
the natural history and management of syphilis, causing
a more rapid course of illness, higher risk of neurologic
complications, and greater risk of treatment failure
with standard regimens. Because many individuals with
syphilis have no symptoms, or have symptoms that
subside without treatment, sexually active individuals
at risk for syphilis should receive regular screening
for syphilis as well as for other STIs. Many clinicians
strongly recommend routine syphilis testing every 3-6
months in patients at risk for syphilis.
In recent years, increasing numbers of syphilis cases
have been reported in HIV-infected men who have sex
with men (MSM), predominantly in major metropolitan
areas. This trend reflects reduced use of safer sex
practices, and is concerning both because syphilis can
have major health consequences if it is undetected and
untreated, and because it is associated with increased
risk of new HIV infections. Risk assessment should
be conducted at each patient visit for unprotected sex
(including oral sex), multiple sexual partners, and use
of recreational drugs (methamphetamine and cocaine,
in particular, are associated with high-risk sexual
practices in MSM). Asymptomatic persons at risk of
acquiring syphilis should be screened at regular intervals
(with rapid plasma reagin [RPR] or Venereal Diseases
Research Laboratory [VDRL] testing, as below),
depending on their risk factors. MSM with multiple
partners should be tested every 3-6 months.
The natural history of untreated syphilis infection is
divided into several different stages based on length of
infection.
Primary Syphilis
Primary syphilis usually manifests after an incubation
period of 1-3 weeks from exposure and is characterized
by a painless self-limiting ulcer (chancre) at the site
of sexual contact. HIV-infected individuals may
have multiple or atypical chancres that might be
misidentified. Some patients have no primary lesion,
or have a primary lesion that is not visible. Associated
Section 6—Disease-Specific Treatment | 6–99
regional lymphadenopathy can occur. HIV-infected
individuals sometimes have a chancre concurrently with
rash typical of secondary syphilis.
Secondary Syphilis
Secondary syphilis usually develops 2-8 weeks after
initial infection and is caused by ongoing replication of
the spirochete, with disseminated infection that may
involve multiple systems. Rash is the most common
presenting symptom; skin lesions may be macular,
maculopapular, papular, or pustular, or may appear as
condyloma lata. The rash often appears on the trunk and
extremities and may involve the palms and soles of feet.
Constitutional symptoms, lymphadenopathy, arthralgias,
and myalgias are common and neurologic or other
symptoms may occur. In the absence of treatment, the
manifestations of secondary syphilis last days to weeks,
then usually resolve to the latent stages.
Latent Syphilis
Latent syphilis follows resolution of secondary syphilis.
As in HIV-uninfected individuals, latent syphilis
is asymptomatic and the diagnosis is determined
by positive serologic tests. Latent syphilis is further
classified as “early latent” if the infection is known to be
less than 1 year in duration, “late latent” if the infection
is known to be greater than 1 year in duration, or
“latent syphilis of unknown duration” if the duration of
infection is not known.
Late or Tertiary Syphilis
Late or tertiary syphilis is due to chronic infection with
progressive disease in any system causing serious illness
and death in untreated patients. The most common
manifestations include neurosyphilis, cardiovascular
syphilis, and gummatous syphilis.
Neurosyphilis
Neurosyphilis can occur at any time after initial
infection, due to spread of the spirochete to the central
nervous system (CNS). In HIV-infected individuals,
neurosyphilis may occur more commonly early in the
course of infection, during secondary or latent syphilis.
It is associated with neurologic symptoms, including
cranial nerve abnormalities (particularly extraocular