How to manage a patient with a positive Venereal Disease Research Laboratory (VDRL) test undergoing a minor otolaryngology (ot) procedure?

Management of VDRL-Positive Patient Undergoing Minor Surgery

Proceed with the minor surgical procedure after confirming the diagnosis with treponemal testing and implementing standard universal precautions—no additional perioperative modifications are required for syphilis status alone. 1, 2

Immediate Preoperative Assessment

Confirm True Syphilis vs. False Positive

• Order confirmatory treponemal testing (FTA-ABS or TPPA) immediately if not already done, as false-positive VDRL occurs in 0.24-2.1% of the general population and up to 10.7% in HIV-positive patients 1
• VDRL titers <1:8 have a 27-31% false-positive rate, while titers ≥1:8 are highly specific for true infection 1, 3
• The surgery can proceed regardless of syphilis status, but confirmation guides postoperative treatment planning 1, 2

Evaluate for Active Disease Requiring Urgent Treatment

Assess for these red flags that would necessitate treatment before elective surgery:

• Neurologic symptoms (cognitive dysfunction, motor/sensory deficits, cranial nerve palsies, meningismus) 1
• Ocular manifestations (uveitis, neuroretinitis, optic neuritis, visual changes) 1
• Auditory symptoms (hearing loss, tinnitus, vertigo) 1
• Active mucocutaneous lesions (chancre, rash, condyloma lata) 1, 3

If any of these are present, perform CSF examination before surgery and treat as neurosyphilis with aqueous crystalline penicillin G 18-24 million units/day IV for 10-14 days 1

Perioperative Management

Standard Precautions Are Sufficient

• Universal precautions adequately protect healthcare workers from syphilis transmission during surgery 4
• Syphilis is transmitted through direct contact with infectious lesions or body fluids, not through routine surgical exposure with proper barrier protection 4
• No special isolation, instrument sterilization, or operative technique modifications are required 1

Document Treatment History

Review medical records for:

• Previous syphilis diagnosis and stage at treatment 2, 3
• Penicillin regimen administered and dates 2, 3
• Post-treatment serologic follow-up showing fourfold titer decline 2, 3

If treatment history is uncertain or inadequate, plan postoperative treatment as late latent syphilis with benzathine penicillin G 2.4 million units IM weekly × 3 weeks 5

Postoperative Follow-Up Plan

For Newly Diagnosed or Untreated Syphilis

Initiate treatment based on clinical stage:

• Primary/secondary syphilis: Benzathine penicillin G 2.4 million units IM × 1 dose 3
• Early latent (<1 year): Benzathine penicillin G 2.4 million units IM × 1 dose 3
• Late latent/unknown duration: Benzathine penicillin G 2.4 million units IM weekly × 3 weeks 3, 5

Serologic Monitoring

• Obtain quantitative VDRL/RPR titer at baseline if not already done 2, 3
• Schedule follow-up at 3,6,9,12, and 24 months post-treatment 3
• Treatment success = fourfold titer decline within 6-12 months (e.g., 1:32 → 1:8) 2, 3
• Some patients remain "serofast" with persistent low titers (<1:8) indefinitely, which does not indicate treatment failure 3

HIV Testing

Test all syphilis patients for HIV, as HIV co-infection affects serologic interpretation and requires more frequent monitoring (every 3 months vs. 6 months) 1, 2, 3

Critical Pitfalls to Avoid

• Never delay necessary surgery solely due to positive syphilis serology in asymptomatic patients without active neurologic/ocular disease 1
• Do not assume VDRL positivity alone confirms active syphilis—always obtain treponemal confirmation 1, 2, 6
• Do not compare VDRL and RPR titers directly—they are not interchangeable, and sequential testing must use the same method 2, 3
• Never skip CSF examination if neurologic or ocular symptoms are present, even with low serum VDRL titers 1
• Do not use ceftriaxone or doxycycline for neurosyphilis—only IV penicillin G is recommended, requiring desensitization if penicillin-allergic 1