Clinician contributions Indigenous Health Infectious Disease Sexual Health

Syphilis – An old disease making a come back

Dr Stephanie Rea provides a timely update on syphilis. Stephanie is currently a junior doctor working in North Queensland. Stephanie has been supported by Dr Darren Russell and Dr Eugene Priscott, sexual health specialists, and Dr Trent Yarwood, an infectious diseases specialist.

Epidemiology ¹

Since 2005 the number of syphilis cases in Australia has almost tripled. The highest risk age group in Australia is 20-39 year olds. Syphilis rates are reported to be approximately 4 times higher in the ATSI population. Since 2011 the number of reported cases of syphilis in MSM irrespective of HIV status has doubled. Currently Cairns is experiencing an increase in syphilis cases predominantly in the MSM/ATSI population.

Who is at risk?

       Taking a thorough sexual history is vitally important.  Ask about:

Sexual practices – do they have sex with men/women/both?

Any new sexual partners?

Does the patient identify as or have a sexual partner who is ATSI?

Have they had any lesions/rash? Can they describe it? How long did it last? Did it self resolve?

If the patient isn’t forthcoming but seems to be at risk – test!

Clinical Features  2

chancre 01

Primary Syphilis

Sec Syphilis 02

Secondary Syphilis

 Primary Syphilis

Chancre – classically a well circumscribed painless indurated ulcer.

Can be found in throat, on the penis, vagina or anus.

Look for local regional lymphadenopathy.

Typically a chancre will self resolve within 4-8 weeks, this is reduced to 1-2 weeks with treatment.

If untreated the affected individual remains infective despite being asymptomatic in this “latency” period.

Additional features of chancres may include: Pain / Multiple / Bleeding / Superficial

The recent outbreak in Cairns has broadened our understanding of how chancres can present.

Chancre 01

A Chancre

Secondary Syphilis

Occurs if primary syphilis is untreated, generally manifesting 3 weeks – 3 months later.

Highly infectious stage.

Signs/Symptoms may include:

Systemic – Fever, fatigue, muscle/joint pains, headache.
Non-itchy erythematous papular rash on the trunk +/- palms/soles.
Condylomata Lata – grey moist raised areas of skin folds near groin, armpits, under breasts.
Red mucosal patches eg mouth/rectum.
Enlarged regional lymph nodes.

Sec Syphilis 01

Secondary Syphilis

Tertiary Syphilis

Rare in Cairns.

Occurs 3-10 years following initial infection if left untreated.

Neurological involvement occurs after 10-30 years and may result in dementia-like presentations, affected vision, cause dizziness and headaches.

Congenital Syphilis

Rare in Cairns.

Prevented if syphilis treated prior to 16 weeks gestation.

Differential Diagnosis

Primary syphilis:

Have a strong suspicion for syphilis, particularly if the history is suggestive, and treat.

The differential for an ulcerated genital lesion includes donovanosis, chancroid & HSV,

Always swab for HSV 1 &2, which may co-exist. There has not been a case of Donovanosis in Australia since 2012. Chancroid is possible in people returning from parts of Asia.

Management  ³ 

Investigations

Syphilis Specific Investigations:

Swab the lesion – Syphilis, HSV 1, HSV 2 PCR,

MC&S

Rapid tests are available at the Cairns Sexual Health Service and some GP clinics in Cairns. These are only useful if the patient does NOT have a past history of syphilis. They can give a result in 20 minutes. Serology must still be taken.

Serology:

EIA (total AB)

RPR – important to establish baseline. Look for a 4x decrease following treatment. If not then consider reinfection.

Other investigations:

Don’t forget where there is one STI there is often another.

Additional Investigations to consider:

Urine – chlamydia/gonorrhea /mycobactrium gentitalium /trichomonas PCR

Swabs – rectal and throat – chlamydia/gonorrhea /MG/trichomonas PCR

BBV Screen – Syphilis/Hepatitis/HIV

Treatment

Early <2 years

1.8g IMI BenPen in buttocks

Latent

One injection per week for 3 weeks of 1.8g IMI Ben Pen in buttocks

 

Note contacts and TREAT!

Primary – 3 months plus duration of symptoms

Secondary – 6 months plus duration of symptoms

Latent – long term partners only

Involve Sexual Health or ID

 

Take home points:

Take a detailed sexual history.

Treat prior to results if history is suggestive.

Where there’s one STI there is often another.

Trace contacts and treat.

Involve sexual health or ID.

Common things are common, think Syphilis!

 

References

  1. The Kirby Institute for infection and Immunity in society – UNSW Medicine, Surveillance reports
  2. Dermnet.NZ – Syphilis – http://www.dermnetnz.org/bacterial/syphilis.html
  3. Australian Sexual Health Alliance – Australian STI Management Guidelines for use in primary care – http://www.sti.guidelines.org.au/sexually-transmissible-infections/syphilis

Photos courtesy of Dr Stephanie Rea and Dr Darren Russell.

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