Syphilis, caused by the spirochete Treponema pallidum, is a sexually transmitted infection that progresses through distinct clinical stages if untreated. Management and follow-up differ between non-pregnant patients and pregnant women due to varying risks and outcomes.
1. Stages of Syphilis
A. Primary Syphilis
Presentation:
A painless ulcer (chancre) at the site of inoculation (e.g., genitalia, anus).
Regional lymphadenopathy.
Diagnosis:
Direct: Darkfield microscopy or direct fluorescent antibody tests from lesion exudates.
Serologic: Nontreponemal tests (e.g., RPR or VDRL) may be non-reactive early in the infection.
B. Secondary Syphilis
Presentation: Systemic symptoms due to hematogenous dissemination, including:
Diffuse, maculopapular rash involving palms and soles.
Condyloma lata: Moist, wart-like lesions on mucous membranes.
Constitutional symptoms: Fever, malaise, and generalized lymphadenopathy.
Diagnosis:
Serologic tests (RPR/VDRL) with confirmation using treponemal tests (e.g., FTA-ABS or TPPA).
C. Early Latent Syphilis
Definition: Asymptomatic phase within the first year post-infection. Diagnosis is based on positive serology.
D. Late Latent Syphilis
Definition: Asymptomatic infection lasting >1 year or of unknown duration, confirmed by positive serology.
E. Tertiary Syphilis
Manifestations:
Cardiovascular: Aortitis, aortic aneurysm.
Neurosyphilis: Tabes dorsalis, general paresis, Argyll Robertson pupils.
Gummas: Granulomatous lesions in the skin, bones, or organs.
Diagnosis:
Positive treponemal tests.
CSF analysis for neurosyphilis (elevated protein, pleocytosis, or reactive VDRL).
2. Syphilis in Pregnancy
Pregnant women with syphilis are at risk for severe complications, including stillbirth, preterm labor, and congenital syphilis.
Management Protocol for Pregnant Women
Primary, Secondary, or Early Latent Syphilis:
Treatment: Benzathine penicillin G, 2.4 million units IM, single dose.
Late Latent or Tertiary Syphilis (non-neurosyphilis):
Treatment: Benzathine penicillin G, 2.4 million units IM weekly for 3 weeks.
Neurosyphilis:
Treatment: Aqueous crystalline penicillin G, 18–24 million units/day IV, divided into doses every 4 hours for 10–14 days.
Penicillin Allergy: Perform desensitization, as penicillin is the only effective treatment during pregnancy.
3. Jarisch-Herxheimer Reaction
Definition: A transient inflammatory response to antibiotic treatment due to the rapid lysis of spirochetes and release of inflammatory mediators.
Clinical Features:
Occurs within 24 hours of initiating therapy.
Symptoms: Fever, chills, headache, myalgia, exacerbation of skin lesions.
Management:
Administer antipyretics (e.g., acetaminophen) for symptomatic relief.
Do not discontinue antibiotics.
Pregnancy Considerations:
May cause uterine contractions, preterm labor, or fetal distress.
Monitor the fetus closely during and after treatment.
4. Follow-Up and Monitoring
A. Non-Pregnant Patients
Follow-Up Protocol:
Perform quantitative nontreponemal serology (e.g., RPR or VDRL) at 6, 12, and 24 months post-treatment.
Expect a fourfold decrease in titers by 6 months (e.g., 1:16 to 1:4).
A fourfold increase suggests reinfection or treatment failure, warranting re-evaluation.
B. Pregnant Women
Follow-Up Protocol:
Conduct serologic testing monthly or every 3 months due to the increased risk of reinfection or treatment failure.
Expect a fourfold decrease in titers by 3 months post-treatment.
A fourfold increase in titers indicates reinfection or treatment failure, requiring retreatment.
Fetal Monitoring:
Perform ultrasound to detect signs of congenital syphilis, including hepatosplenomegaly, hydrops fetalis, or placental thickening.
5. Management and Follow-Up Comparison
Aspect | Non-Pregnant Patients | Pregnant Women |
Treatment | Standard penicillin protocols. | Identical to non-pregnant patients. |
Follow-Up Timing | 6, 12, and 24 months. | Monthly or every 3 months during pregnancy. |
Expected Serologic Response | Fourfold decrease in titers within 6 months. | Fourfold decrease in titers within 3 months. |
Reinfection/Treatment Failure | Fourfold increase triggers re-evaluation. | Immediate re-evaluation upon fourfold increase. |
Additional Monitoring | None. | Fetal monitoring with ultrasound. |
6. Key Points from CDC and WHO Guidelines
Penicillin G remains the gold standard treatment for syphilis across all stages.
Serologic titers (RPR/VDRL) are crucial for evaluating treatment efficacy and detecting reinfection.
Pregnant women require closer monitoring due to risks to the fetus, with earlier expected serologic improvement.
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