What are the key history points to consider when suspecting syphilis in a high-risk adult patient with potential history of sexually transmitted infections (STIs) and possible intravenous drug use?

Key History Points for Suspected Syphilis

When evaluating a high-risk adult for syphilis, obtain a detailed sexual history including number and gender of partners, condom use, history of STIs, and specifically ask about recent exposure to partners with known syphilis within the past 90 days, as this determines need for presumptive treatment. 1, 2

Essential Sexual History Components

• Document all sexual contacts from the past 6 months if secondary syphilis is suspected, or past 3 months for primary syphilis, as these partners require evaluation and presumptive treatment 1, 2
• Ask specifically about men who have sex with men (MSM) status, as this population has higher prevalence and azithromycin should never be used in MSM due to resistance 1, 2
• Inquire about sex work or exchange of sex for drugs/money, which increases risk 3
• Document condom use patterns and whether patient has multiple concurrent partners 3

Critical Symptom Timeline

• Ask about painless genital, oral, or anal ulcers (chancre) in the past 3-6 months that may have resolved spontaneously, indicating primary syphilis 4, 5
• Inquire about rash involving palms and soles, which is highly characteristic of secondary syphilis 2, 6
• Ask about generalized lymphadenopathy, sore throat, or oral lesions occurring weeks to months after potential exposure 5, 6
• Document any neurologic symptoms including headache, vision changes, hearing loss, confusion, or altered mental status suggesting neurosyphilis 1, 7
• Screen for ocular symptoms such as blurred vision, eye pain, or photophobia, as uveitis and iritis can occur in secondary syphilis 1, 6

High-Risk Behavior Assessment

• Document intravenous drug use history, as this increases risk and may indicate need for more comprehensive STI screening 8
• Ask about housing instability or homelessness, which correlates with higher syphilis rates and atypical presentations 8
• Inquire about recent incarceration, as this is associated with increased STI risk 3
• Document HIV status or last HIV test date, as HIV-infected patients require different monitoring protocols (every 3 months vs 6 months) and have higher neurosyphilis risk 1, 7

Previous STI and Treatment History

• Review documented history of prior syphilis treatment, including specific penicillin regimen, stage treated, and dates, as inadequate treatment requires re-treatment 4
• Ask about history of other STIs including gonorrhea, chlamydia, herpes, and hepatitis, as coinfections are common 6
• Document previous syphilis serologic test results and titers if available, as fourfold changes are clinically significant 4
• Inquire about penicillin allergy history, though note that pregnant women and those with neurosyphilis must undergo desensitization regardless 1, 2

Partner Notification History

• Ask if patient has been notified by a sexual partner about syphilis diagnosis, as exposure within 90 days requires presumptive treatment even if seronegative 1, 2
• Document whether patient can identify and contact recent partners for notification purposes 1

Pregnancy Status (for Women)

• Determine pregnancy status immediately, as only penicillin prevents congenital syphilis and all alternatives are inadequate 1, 2
• Document trimester if pregnant, as Jarisch-Herxheimer reaction may precipitate premature labor or fetal distress in second/third trimester 1, 2

Common Pitfalls to Avoid

• Do not rely solely on patient recall of "negative STI testing" without reviewing actual documented results and dates, as many patients confuse screening tests 4
• Do not assume absence of symptoms rules out syphilis, as latent syphilis is asymptomatic by definition and represents 30.5% of cases 1, 6
• Do not skip HIV testing discussion, as all syphilis patients require HIV screening and coinfection dramatically alters management 1, 2