37- Syphilis-Neurosyphilis

To know:

1- All HIV+ patients who have had syphilis in the past may relapse even if they had the correct treatment in the past.

2- For HIV+ patients, symptoms of secondary syphilis can come during the course of tertiary syphilis/neurosyphilis!  And symptoms of primary syphilis can be associated with secondary syphilis!  All of this means that without lab tests, syphilis is often an diagnosis of exclusion.

3- Skin lesions of syphilis can be contagious, especially palm lesions!?!  This is a danger for health workers...  It is why we sometimes choose to treat even if not sure of diagnosis.  Our ability to make direct hand contact with any suffering patient should be maintained if at all possible...

4- Availability of lab is not the final solution for diagnosis because VDRL/TPH can be negative for treponema positive patient in end of aids evolution.

Diagnosis:

Lesions of secondary syphilis are often aspecific or poorly specific (papulo-macular rash, symmetrical, including face...)

// pxx428- 429- 430- 431- 432- 433- 434- ptx065- 066 //

1. BUT some unusual symptoms must alert any health worker:
• "Condylomata Lata" //ghx078-079 ?// Granular wart.  May easily be confused with "Condyloma Acuminata"//ghx010-017-axx006// ghx026...// axx013...// Lata has a large root with flatter flesh and a less granulous appearance than "Condyloma Acuminata".  C.Acuminata looks more like a "polyp" and C. Lata more like a "big granulous papule".  Condyloma Lata is a symptom of syphilis and has to be treated as syphilis.  Condyloma Acuminata should be treated with podophilin if available, but for inexperienced workers a doctor should show how to do this procedure the first time because errors cause painful deep wounds!  But!!!  -- association of Condyloma Acuminata with syphilis is common (the same is true also for gonorrhea and for chlamydia).  It may be better to treat C. Acuminata as "invisible Syphilis"!  (See also "4-Anus" & "15-Genital Wart“)
• Papular rash on soles and palms //pxx081// pxx079...// pxx077...// pxx074// pxx140...142// pxx331...// Usually NO pruritus!
• Alopecia areata //ptx001 //
• Chancre without pain (rare in a hospice of course because means recent unprotected relations) (see 15-Genital Ulcers)

We treat all the above symptoms as syphilis until proven otherwise.

2. Other less specific symptoms include
• Papular and papullo-squamous rash sometimes involving the face Usually NO pruritus.
• Symmetrical paresis of legs and/or arms
• Any other neuro focal signs (symmetrical or not)
• Deafness
• Acute meningitis
• Stroke
• Acute vertigo
• Headache
• Convulsion
• Confusion/delirium
• Dementia
• Tongue lesions like "large aphthous ulcer"
• (...)

We treat these symptoms as syphilis only after rejecting other diagnoses and/or after failure of other treatments (toxoplasmosis, allergy, skin infections...)

3. Argyll Robertson Syndrome: Pupil is constricted.  It is unreactive to light but constricts in accommodation-convergence (light-near dissociation).  If you observe this sign, your patient very likely has syphilis...  You should treat.

Treatment

• 1°- Check that patient is not allergic to penicillin with subcutaneous injection of benzatine penicillin (only 0.3cc)
• 2°- If no allergy, the same day, we inject 1cc of dexamethasone IM + 1 million international units of procaine penicillin IM...  (dexa is to prevent the "Jarisch-Herxheimer Reaction").
• 3°- The next day 2.4 million units of procaine penicillin IM (1.2 million IM in each buttock) for 3 doses at one week intervals
• 4°- If you suspect neurosyphilis it is best to inject 2.4 million units for 10-14 consecutive days and add probenecid 2g daily.

If patient is allergic to penicillin

• Doxycycline 100mg, 2 times each day (after meals) for 30 days... But some authors say it is useless in cases of aids...
• For Neurosyphilis consider ceftriaxone 2gr  IV once daily for 10 days although there is no proven alternattive to PEN.