Does a patient with a history of positive syphilis (Venereal Disease Research Laboratory (VDRL)) titer in 2018 still require treatment?

Management of a Patient with a Positive Syphilis Titer from 2018

A patient with a positive syphilis VDRL titer from 2018 still requires treatment if they have not received appropriate therapy previously. 1, 2

Evaluation of Past Treatment Status

• First determine if the patient received adequate treatment after the positive test in 2018 2
• Review medical records for documentation of appropriate penicillin regimen based on the stage of syphilis at that time 1
• Check for evidence of serologic response to treatment (fourfold decline in nontreponemal test titers within 6-12 months) 1

Treatment Decision Algorithm

If No Prior Treatment:

• Treat according to the presumed stage of syphilis 2
• If duration is unknown or greater than one year (which applies in this case from 2018), treat as late latent syphilis with benzathine penicillin G 2.4 million units IM once weekly for three consecutive weeks 2

If Previously Treated:

• If documentation confirms adequate treatment with appropriate follow-up showing serologic response, no retreatment is necessary 3
• If treatment history is uncertain or inadequate, treat as late latent syphilis 1

Monitoring After Treatment

• Follow-up serologic testing should be performed at 6,12, and 24 months after treatment for latent syphilis 2
• A fourfold decline in nontreponemal test titer (equivalent to a change of two dilutions) is considered clinically significant evidence of adequate treatment response 1
• Some patients may remain serofast (persistent low-level positive titers) despite adequate treatment, which does not necessarily indicate treatment failure 1, 4

Special Considerations

HIV Testing

• All patients with syphilis should be tested for HIV infection 1
• HIV-infected patients may have atypical serologic responses and require more frequent monitoring (every 3 months) 1, 2

Neurologic Evaluation

• Consider CSF examination if there are neurologic or ophthalmic symptoms 1
• Even with appropriate treatment for early syphilis and serologic response, progression to neurosyphilis can occur in some cases 5

Penicillin Allergy

• For penicillin-allergic patients, doxycycline (100 mg orally twice daily for 14 days) can be used for early syphilis, but for late latent syphilis, penicillin desensitization is preferred 1

Common Pitfalls to Avoid

• Do not rely solely on treponemal tests (such as FTA-ABS or MHA-TP) to assess treatment response, as these typically remain positive for life regardless of treatment 1, 6
• Do not confuse serofast status with treatment failure - approximately 8-11% of patients with early syphilis may remain serofast even after 30 months of follow-up 4
• Do not assume that a single positive titer without symptoms means the infection is inactive - latent syphilis can progress to late complications if untreated 2
• Do not miss the opportunity to screen and treat partners - all sexual contacts should be evaluated 1