Syphilis
The great masquerader is back with a vengeance
Syphilis, caused by the spirochaete Treponema pallidum, is an old disease. Many notable figures throughout history
are thought to have suffered from this scourge. It remains exquisitely sensitive to penicillin so, in theory, should be easily
treatable.
394
1000
260
500
110 143 179
QLD
NT
NSW
2015*
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
Figure 2: Age and Sex for Syphilis cases <2 years duration
2015
350
300
Male
250
Female
200
150
100
50
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
0
Figure 3: Notified cases Congenital Syphilis
25
20
0
2
6
15
WA
VIC
3
2
5
10
SA
1
QLD
0
2
0 0
3
2
2009
2007
2005
2003
2001
1999
0
NT
2 0
3
0
NSW
ACT
0
2015
1
2013
1
0 3
TAS
2011
5
5 6 6
1997
Risk of transmission of syphilis from a pregnant mother to her fetus depends
on the stage of syphilis during pregnancy. Management is clearly outlined in
the ASID Management of Perinatal Infections Guidelines (https://www.asid.
net.au/documents/item/368)
389 336
SA
ACT
Early latent syphilis is infection of less than two years' duration where the patient is asymptomatic.
Late latent syphilis is defined
as latent (asymptomatic)
syphilis of longer than
two years' duration, or of
unknown duration. Tertiary
syphilis refers to syphilis
of longer than two years'
duration, or of unknown
duration, with cardiovascular,
central nervous system or
skin and bone (gummatous
syphilis) involvement.
200 192 228 337
492
0
1995
•
Progression to secondary syphilis occurs over the following months and
presents as an acute systemic illness with rash, which is usually truncal,
but also involving palms and soles (Figure 4), condylomata lata (clusters
of soft, moist lumps in skin folds of the anogenital area), mucosal lesions,
alopecia, lymphadenopathy, hepatitis, or meningitis.
TAS
1991
•
Primary syphilis usually manifests as a chancre (an anogenital or, less
commonly, extragenital painless, but also sometimes painful, ulcer with
indurated edges).
VIC
1500
Number of cases
•
WA
5-9
Presentation
Early or infectious syphilis (less than two years' duration) includes primary,
secondary and early latent syphilis (Algorithms 1 and 2).
2000
10-14
Co-infections with other sexually transmitted infections (STIs) are common
and should always be tested for simultaneously. Similarly, all STI screens
should include a test for syphilis. At-risk patients require screening for
co-existing chlamydia, gonorrhoea and/or and trichomonas if the patient
belongs to the ATSI group. Screening for HIV, hepatitis A, B and C should also
occur, with hepatitis A and B vaccination in those who are non-immune. The
recommended regular screening for asymptomatic gay and bisexual males
is outlined in the now renamed STIGMA guidelines (http://stipu.nsw.gov.au/
wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf).
2500
1993
In the Northern Territory and Queensland, the emerging risk groups are
young Aboriginal and Torres Strait Islanders (ATSI), particularly people from
the north of the State. In this group, in which young females are infected,
there is now a real risk of new cases of congenital syphilis (Figures 2 and
3). In other geographical areas, gay and bisexual males form the major risk
group.
Figure 1: Syphilis notifications <2 years duration
0-4
Over the past two years, the number of notified cases of infectious syphilis –
syphilis of less than two years' duration (Figure 1) — has continued to grow.
Treponema pallidum screening test*
Syphilis Antibody
If high risk, repeat serology during
incubation period 9–90 days.
If pregnant and high risk repeat at
28–32 weeks gestation.
NEGATIVE
SCREENING FOR SYPHILIS
ALGORITHM 1
POSITIVE
Non-treponemal test
RPR titre +ve
Treponemal test
TPPA +ve
Non-treponemal test
RPR titre +ve/-ve
Treponemal test
TPPA -ve
Non-treponemal test
RPR titre -ve
Treponemal test
TPPA +ve
High-risk subject or symptomatic: possible
false negative. Occurs rarely in early infection
Past treated/latent
infection
Repeat in 2–4 weeks
Treponemal test
TPPA -ve
Treponemal test
TPPA +ve
Biological false +ve no evidence of
syphilis infection
SYPHILIS
Syphilis antibody positive (seropositive)
MANAGEMENT OF SEROPOSITIVE SYPHILIS
ALGORITHM 2
DETERMINE STAGE
Clinical history, examination, past test results
(Syphilis register 1800 032 238)
PRIMARY
Chancre present
(PCR positive)
RISK OF FOETAL INFECTION
HIGH
SECONDARY
Systemic illness – fever, rash,
hepatitis, lymphadenopathy,
meningoencephalitis
RISK OF FOETAL INFECTION
MODERATE
LATENT
Asymptomatic
<2 years-early
LATENT
Asymptomatic
>2 years-late
RISK OF FOETAL
INFECTION
LOW
RISK OF FOETAL
INFECTION
LOW
RISK OF FOETAL INFECTION
NEGLIGIBLE
CONTACT TRACE reorder after TREATMENT
1O: 3 months + duration of symptoms
2O: 6 months + duration of symptoms
Early latent: 12 months
TREATMENT
Pencillin dose according to stage
Procaine penicillin or benzathine penicillin
De-sensitise if necessary
REPEAT RPR (6 weeks, 3 months, 6 months and 12 months)
Rate and level of fall dependent on stage that treatment commences
1O: RPR non-reactive in 12 months
2O: RPR non-reactive in 12 months
Latent/Tertiary: RPR may remain weakly
positive indefinitely.
Consider retreatment:
Clinical signs of syphilis present
Sustained 4 fold increase in RPR
Failure of RPR to decrease 4 fold in 1 year
*The Syphilis TP Chemiluminescent Microparticle Immunoassay (CMIA) is a screening test for specific T. pallidum antibodies.
Infectious stage
SULLIVAN NICOLAIDES PTY LTD • ABN 38 078 202 196
A subsidiary of Sonic Healthcare Limited • ABN 24 004 196 909
24 Hurworth Street• Bowen Hills • Qld 4006• Australia
Tel (07) 3377 8666 • Fax (07) 3878 7409
PO Box 2014 • Fortitude Valley • Qld 4006 • Australia
www.snp.com.au
TERTIARY
Cardiovascular
Neurological
Gummatous lesions
For further information
Please contact the microbiologist
at Sullivan Nicolaides Pathology
P: (07) 3377 8666 or 3377 8534.
 Sullivan Nicolaides Pathology 2016
Meridio 197065 November 2016
Correct at time of printing.