What is the recommended review of systems and treatment for a patient suspected of having syphilis?

Recommended Review of Systems and Treatment for Suspected Syphilis

The recommended review of systems for suspected syphilis should focus on identifying symptoms across all stages of infection, followed by treatment with benzathine penicillin G as the primary therapy, with specific dosing regimens based on the stage of infection. 1

Clinical Evaluation and Review of Systems

History and Physical Examination

• Sexual history: Recent partners, types of sexual contact, condom use
• Previous STI history: Prior syphilis infections or other STIs
• Systemic symptoms: Fever, malaise, headache, sore throat, weight loss
• Skin examination: Look for:
  • Primary stage: Painless chancre (genital, anal, oral regions)
  • Secondary stage: Diffuse maculopapular rash (including palms/soles), condyloma latum, mucous patches
• Lymph node examination: Regional lymphadenopathy (primary) or generalized lymphadenopathy (secondary)
• Neurological assessment: Headache, visual/hearing changes, cranial nerve palsies, cognitive dysfunction, motor/sensory deficits 2
• Cardiovascular assessment: Signs of aortitis or aortic insufficiency (tertiary stage)
• Ocular examination: Uveitis, neuroretinitis, optic neuritis 2

Laboratory Testing

• Serologic testing:
  • Nontreponemal tests (RPR or VDRL) for screening
  • Treponemal-specific tests for confirmation
• CSF examination indicated for patients with:
  • Neurologic or ophthalmic signs/symptoms
  • Evidence of active tertiary syphilis
  • Treatment failure
  • HIV infection
  • Serum nontreponemal titer ≥1:32 (unless duration known to be <1 year)
  • Planned non-penicillin therapy (unless duration known to be <1 year) 2, 1
• HIV testing for all patients with suspected syphilis 2, 1

Treatment Recommendations

Primary, Secondary, and Early Latent Syphilis (<1 year duration)

• First-line treatment: Benzathine penicillin G 2.4 million units IM in a single dose 1
• For penicillin-allergic non-pregnant patients:
  • Doxycycline 100 mg orally twice daily for 14 days 1, 3
  • Tetracycline 500 mg orally four times daily for 14 days 1

Late Latent Syphilis or Latent Syphilis of Unknown Duration (>1 year)

• First-line treatment: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM at 1-week intervals 1
• For penicillin-allergic non-pregnant patients (after CSF examination to exclude neurosyphilis):
  • Doxycycline 100 mg orally twice daily for 28 days 1, 3
  • Tetracycline 500 mg orally four times daily for 28 days 1

Neurosyphilis

• First-line treatment: Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours for 10-14 days 2, 1
• Alternative regimen (if compliance can be ensured):
  • Procaine penicillin 2.4 million units IM once daily PLUS
  • Probenecid 500 mg orally four times daily, both for 10-14 days 2
• Some experts recommend adding benzathine penicillin G 2.4 million units IM weekly for up to 3 weeks after completing neurosyphilis treatment 2

Special Populations

Pregnant Patients

• Must receive penicillin-based treatment regardless of allergy status
• Penicillin-allergic pregnant patients should undergo desensitization followed by appropriate penicillin treatment 1
• Doxycycline and tetracycline are contraindicated in pregnancy 1

HIV-Infected Patients

• Same treatment regimens as HIV-negative patients
• More careful follow-up due to potentially higher rates of treatment failure and neurologic complications 2, 1
• Consider CSF examination before treatment for HIV-infected patients with late latent syphilis 2, 1

Follow-Up

• Quantitative nontreponemal tests (RPR or VDRL) at 6,12, and 24 months after treatment 1
• For primary and secondary syphilis: Clinical and serological evaluation at 3 and 6 months 1
• Treatment success: Four-fold decrease in nontreponemal test titers within 12-24 months 1
• For neurosyphilis: CSF examination every 6 months until cell count normalizes; re-treatment if cell count hasn't decreased after 6 months or if CSF isn't normal after 2 years 2

Partner Management

• All sexual partners exposed within 90 days of primary, secondary, or early latent syphilis diagnosis should be treated presumptively, even if seronegative 1
• Long-term partners of patients with late latent syphilis should be evaluated clinically and serologically and treated based on findings 1

Common Pitfalls to Avoid

• Failing to test for HIV in all syphilis patients
• Missing neurosyphilis in patients with neurological symptoms
• Using macrolides (e.g., azithromycin) empirically due to widespread resistance 4
• Inadequate follow-up of serological response to treatment
• Forgetting to evaluate and treat sexual partners
• Overlooking the need for CSF examination before using non-penicillin therapy in late syphilis