What is the recommended treatment for a 74-year-old female with late latent syphilis?

Treatment for Late Latent Syphilis in a 74-Year-Old Female

The recommended treatment for a 74-year-old female with late latent syphilis is benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals. 1

Diagnostic Interpretation

The patient's serologic profile (FTA Non-Reactive, RPR Quantitative 1:1 High, RPR Reactive Abnormal) with no known history of syphilis or previous treatment indicates late latent syphilis of unknown duration. When the duration of infection cannot be established as being acquired within the past year, patients should be managed as having late latent syphilis.

Treatment Algorithm

First-line Treatment:

• Benzathine penicillin G 7.2 million units total
  • Administered as three doses of 2.4 million units IM
  • Given at 1-week intervals 2, 1

For Penicillin-Allergic Patients:

• Doxycycline 100 mg orally twice daily for 28 days 2, 3
  • OR
• Tetracycline 500 mg orally four times daily for 28 days 2

Pre-Treatment Considerations

1. CSF Examination: Consider CSF examination before initiating therapy if any of the following are present:

   • Neurologic or ophthalmic signs/symptoms
   • Evidence of active tertiary syphilis
   • Treatment failure
   • HIV infection 2

2. HIV Testing: All patients with syphilis should be tested for HIV infection 2

3. Clinical Evaluation: Examine for evidence of tertiary disease (aortitis, gumma, iritis) 2

Follow-Up Protocol

• Clinical and serological evaluation at 6 and 12 months after treatment 1
• Treatment success is defined as a four-fold decrease in non-treponemal test titers within 12-24 months 2
• If titers fail to decline appropriately or if symptoms develop, reevaluate for neurosyphilis and consider retreatment 2

Special Considerations

Age-Related Factors

• In elderly patients, careful monitoring for adverse reactions to treatment is important
• Consider comorbidities that may affect treatment tolerance

Partner Management

• Evaluate long-term partners clinically and serologically 1
• Treat based on evaluation findings

Common Pitfalls to Avoid

1. Inadequate Treatment Duration: Using early syphilis treatment regimens (single dose) for late latent syphilis is insufficient and may lead to treatment failure

2. Improper Follow-Up: Failing to monitor serologic response can miss treatment failures

3. Overlooking Neurosyphilis: Not considering CSF examination in patients with neurological symptoms can lead to inadequate treatment

4. Alternative Regimens Without Monitoring: When using doxycycline or tetracycline alternatives, close clinical and serological follow-up is essential 2

5. Benzathine Penicillin Shortage: Be aware that shortages have been reported; have alternative plans ready if the preferred treatment is unavailable 4

The evidence strongly supports using benzathine penicillin G as the first-line treatment for late latent syphilis, with the three-dose regimen providing the most reliable outcomes for preventing progression to tertiary syphilis and its associated morbidity and mortality.