Communication is the key. It is crucial. This is the case in all relationships regardless if it is at work or with your friends and family. This is no different in medicine, whether it be between the patient and provider, or provider to provider. Communication is crucial.


A new patient came to my clinic during my final preceptorship as a student.We discussed the past medical history, medications, and screening recommendations, and the encounter went very smoothly. No medications or chronic illnesses….so I thought.


Just like with all patients that are new, I always request past medical records from their past primary care provider as well as any records from past or current specialists. As students reading, you will find out soon that sometimes your job as a clinician is just as much reading old medical records as it is interacting and treating patients.


As I scanned through the patient’s records, I got to the laboratory results from the past, and things are looking great, normal complete blood counts, normal complete metabolic panels, normal TSH, lipid panel, A1c, urinalysis, and so on and so forth.


Until I saw one positive test… a positive RPR. I showed this to my preceptor, and this perked our ears a bit, and I continued to read pages and saw the next test…. a positive VDRL, findings that are concerning for possible syphilis.


I flipped through the remaining pages, but there was no other documentation on these findings, and no other listed testing or treatment. I was confused. How was there nothing else documented? No follow up testing to confirm a diagnosis? No treatment?


Our office staff got on the phone to speak with the past primary care provider’s office who found these tests to be positive. They noted that the patient was made aware of the diagnosis and scheduled to have confirmatory testing, but never showed up back to the clinic. This was the first chink in the proverbial chain of communication.


The second question I had was, why did the patient not disclose this information during our encounter? The topic of sexually transmitted diseases was discussed during the appointment, but I do understand that talking about these topics can be stressful and embarrassing to patients. I reflect back thinking, what could I have said differently to find this piece of information. This was the second chink in the chain of communication.


The prevalence of syphilis has been on the rise over the last decade. It is caused by a spirochete called Treponema pallidum and is spread from individual to individual through sexual contact. In 2000 primary and secondary cases of Syphilis were at an all-time low at 2.1 cases per 100,000 persons. However, outbreaks of infection started occurring in men who have sex with men.1


In 2006 it was found that the prevalence of this infection increased by 15.2 percent from the initial data in 2000. The most substantial population affected by the disease has been found to be men who have sex with men. However, there has been an increase in the prevalence of women seen with the disease as well.1


There are several stages of syphilis including primary, secondary, latent and tertiary. The characteristics of each phase is listed below.



The classic finding in primary syphilis is the presences of a nontender chancre. This is often the findings that patients can come into your clinic with. However, the spot can go unnoticed if it is in a difficult area to visualize such as the anus or cervix.1 Chancres can also be seen in other places than the genitals including the fingers, oral cavity, and nipples, and also there can be more than one present at a time.



If primary syphilis is not treated, then it can progress to secondary syphilis approximately six to eight weeks after the initial infection. Secondary syphilis presents with a pink to red maculopapular rash on the extremities, trunk, and face. In addition to the body-wide rash, the patient may have oral ulcerations, alopecia with the “moth-eaten” appearance, and condylomata lata and lues maligna.1



If a case of syphilis goes untreated in the primary and secondary stage is can progress to the latent phase which is characterized by having an absence of symptoms.Latent syphilis is further divided into early and late phases. Regarding transmission, those in early latent phase can spread the disease, whereas those with late latent are thought not to be able to spread the infection.1


The CDC notes early latent syphilis as being within one-year duration without symptoms of primary or secondary syphilis. Late latent syphilis is the time beyond one year in which the patient does not have symptoms.1


In tertiary syphilis, there is a persistent low level of Treponema pallidumpresent that the body has created a self-harming autoimmune response against. The three most common presentations of tertiary syphilis are neurosyphilis, late benign syphilis, and cardiovascular syphilis.1


Neurosyphilis occurs if the Treponema pallidum penetrates the blood-brain barrier leading to headaches, decreased cognition, and personality changes. Cardiovascular syphilis affects the large blood vessels often presenting with ascending aortitis. Late benign syphilis presents with granulomas, psoriatic plaques, and gummas on the skin.1


Neurosyphilis can not only present in tertiary syphilis but can occur at any stage of infection.


Patients who are suspected to have syphilis are typically screened with nontreponemal tests which consist of the Rapid Plasmin Reagin (RPR) and the Venereal Disease Research Laboratory (VDRL). These tests return positive results within three weeks of the first symptom onset. Therefore, if a patient presents to your clinic with a painless chancre that showed up one day ago, these tests may be negative still.1


This makes diagnosis in the primary phase difficult. Those with strong clinical indications of syphilis should therefore have a repeat VDRL and RPR in two weeks.


In this time period if there is a high suspicion of Syphilis, dark field microscopy can be used to see the pathogen directly; however, this requires specialized equipment to complete.



Patients who have a positive RPR or VDRL should undergo treponemal-specific testing with fluorescent treponemal antibody absorption (FT-ABS) or the Treponema pallidum particle agglutination (TPPA). Other testing includes the T. pallidum enzyme immunoassay (TP-EIA), or chemiluminescence immunoassay (CIA), which look for different antigens.1


If testing confirms the diagnosis of syphilis, the patient should then also be screened for HIV due to the increased risk of co-infection, and also should be reported to state and local health departments.



Treatment of syphilis depends on the stage of disease when diagnosed. Primary, secondary, and latent syphilis are treated with a single dose of IM penicillin G of 2.4 million units. For late latent syphilis, tertiary syphilis, or unknown staged syphilis, the same dose of penicillin is used, just done once weekly for three total weeks.1


Neurosyphilis requires the use of 3-4 million units of IV crystalline penicillin G every four hours for ten to fourteen days duration. Patients may develop acute febrile illness within the first 24 hours of administration of antibiotics called the Jarisch-Herxheimer reaction. This occurs due to the massive destruction of pathogens, causing the release of a large number of inflammatory cytokines into the bloodstream.



Following treatment of primary, secondary, and latent syphilis, repeat VDRL and RPR should be completed, often showing a fourfold decrease in titers over three to six months. All patients should have repeat nontreponemal testing done six and twelve months after treatment as well.1


Newer point of care immunochromatographic strip testing has been suggested to be used in high-risk populations for screening in underdeveloped areas. Although the United States FDA does not approve these tests, studies have shown that they have a sensitivity of 78 to 100 percent and a specificity of 97 to 99 percent.1


I hope today’s article showed the importance of communication, no matter what you do for a living. Sometimes you can do everything to the best of your ability and still come up short or not get the whole story, and often you may not have done anything wrong at all. Make sure as healthcare providers we stay persistent and leave no stone unturned.




Sources:


1.Am Fam Physician. Syphilis: A Reemerging Infection. 2012;86(5):433-440.


2.UpToDate. Syphilis: Screening and Diagnostic Testing. Accessed: March 7, 2018.


3.Ferri’s Clinical Advisor. Syphilis. 2017.


This article, blog, or podcast should not be used in any legal capacity whatsoever, including but not limited to establishing standard of care in a legal sense or as a basis of expert witness testimony.No guarantee is given regarding the accuracy of any statements or opinions made on the podcast or blog.