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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
6–100| Clinical Manual for Management of the HIV-Infected Adult/2006 or facial muscle palsies, tinnitus or hearing loss) or symptoms of meningitis. Uveitis or other eye disease may occur in conjunction with neurosyphilis. S: Subjective Symptoms will depend on the site of initial infection, the stage of disease, and whether neurosyphilis is present. Symptoms are not present in all patients. If symptoms are present, the patient may complain of: ♦ ♦ ♦ ♦ ♦ Painless sore(s) or ulcer(s) in the genital area, vagina, anus, or oral cavity New rash, usually on the trunk, soles, and/or palms; patchy hair loss Fever, malaise, swollen glands, arthralgias, myalgias Altered mental status, weakness, paralysis Neurosyphilis: vision changes, eye pain, hearing loss, headaches, dizziness, generalized weakness, seizures, confusion, changes in personality or affect Conduct a targeted history, asking the patient about symptoms listed above, including duration; inquire about other or associated symptoms Ascertain the following: ♦ ♦ ♦ ♦ ♦ Previous diagnosis of syphilis New sex partner(s) in past 90 days (for primary or secondary syphilis) Unprotected sex (oral, vaginal, anal) Date of last syphilis test Possible pregnancy O: Objective Check for fever, document other vital signs Perform a complete examination including: ♦ ♦ ♦ ♦ ♦ ♦ Skin and mucosal areas (including the genitals, palm, and soles): rash, gummas, granulomas, patchy hair loss Oropharynx: chancres, mucous patches, condyloma lata Lymph nodes Heart: murmurs Ophthalmic examination Neurologic examination (mental status, cranial nerves [including visual acuity], sensory, motor, reflexes, coordination, gait): abnormal mental status, visual acuity changes, extraocular movement abnormalities, neurosensory hearing loss, facial palsy, paraesthesias, paralysis, hemiplegia, hyperactive reflexes, ataxia A: Assessment Because syphilis has a wide range of manifestations, the differential diagnosis is broad. It is important to consider syphilis as a possible cause of many presenting illnesses. A partial differential diagnosis includes: ♦ ♦ ♦ ♦ ♦ ♦ Other causes of maculopapular rashes: pityriasis, drug eruption, condyloma, folliculitis, psoriasis, acute HIV infection Other causes of genital ulcerative disease: herpes simplex virus (HSV), chancroid Other causes of ocular disease; glaucoma, cytomegalovirus (CMV) retinitis, CMV immune reconstitution uveitis, HSV keratitis Other causes of neurologic disease: stroke, Bell's palsy, CNS lymphoma, toxoplasmosis, meningitis Other causes of cardiac murmurs: bacterial endocarditis, congenital abnormalities Other causes of systemic symptoms (eg, fever, malaise, adenopathy): acute HIV infection, acute hepatitis, other infections or malignancies P: Plan Diagnostic Evaluation Darkfield examination and direct fluorescent antibody Darkfield examination and direct fluorescent antibody (DFA) testing of a sample from suspicious genital or anal chancres or moist dermatologic lesions (not oral lesions) are definitive tests for syphilis. Serologic tests Nontreponemal tests (RPR or VDRL) are most sensitive in primary and secondary syphilis when titers are high, though the response may be delayed in HIV-infected patients (typically nontreponemal tests are positive within 3 months after infection). Because false-positive results may occur, positive nontreponemal test results must be confirmed with a treponemal test. Titers may be used to follow response to treatment; a fourfold change in titer is considered a significant change. Note that the same nontreponemal test should be used consistently for a single patient; RPR titers cannot be compared with VDRL titers.
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Clinical Manual for Management of t
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Table of Contents Clinical Manual f
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Clinical Manual for Management of t
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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♦ ♦ ♦ ♦ ♦ | Clinical Manu
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1-2 | Clinical Manual for Managemen
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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♦ ♦ ♦ ♦ ♦ Vital signs: No
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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♦ ♦ ♦ ♦ ♦ Navas E, Martin
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Eye Problems Background The immunos
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of
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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♦ ♦ ♦ ♦ ♦ Some patients t
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Page 288 and 289: Kaposi Sarcoma Background Kaposi sa
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Page 292 and 293: Molluscum Contagiosum Background Mo
Page 294 and 295: Mycobacterium avium Complex Backgro
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Page 298 and 299: Mycobacterium tuberculosis: Treatme
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Page 302 and 303: Table 1. Regimens for Treatment of
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 342 and 343: Linear Gingival Erythema Background
Page 344 and 345: Background Necrotizing ulcerating p
Page 346 and 347: Oral Health Background Examination
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Suicidal Ideation Background Transi
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Section 8—Neuropsychiatric Disord
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P: Plan ♦ ♦ ♦ ♦ ♦ Check t
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Correctional Settings Background Ca
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Adherence Adherence is one of the m
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Karnofsky Performance Scale Backgro
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