Syphilis in Adult Patients

Preferred treatments

• Recommended treatments are the same for pregnant patients and people with HIV
• An acute febrile reaction with headache, myalgia, rash and mild hypotension may occur within 24 hours of starting therapy (Jarisch-Herxheimer reaction); this is a non-allergic inflammatory reaction
• Symptoms usually resolve within 12 to 24 hours; manage with NSAIDs or acetaminophen as needed
• Pregnant patients should be advised to contact their health-care provider if symptoms occur because the reaction may precipitate uterine contractions, preterm labour or fetal distress in the second half of pregnancy
• All patients with syphilis should be tested for HIV

Penicillin allergy

• Many people who report a penicillin allergy can safely receive penicillin after a standardized assessment
• For confirmed penicillin allergy, consult Infectious Diseases

Testing and treatment of sexual contacts

• All partners with sexual contact with the index case of primary, secondary or early latent syphilis within 90 days should be presumptively treated for infectious syphilis, even if serology is negative; notify the local public health authority where the patient resides (for Toronto, Toronto Public Health STI Program: 416-338-2373).
• Partners with sexual contact after 90 days should be treated based on clinical assessment and serology; if results are not available, presumptively treat for infectious syphilis.

Terminology

• Primary syphilis: New infection with T. pallidum; most commonly presents as a painless chancre and regional adenopathy
• Secondary syphilis: May follow untreated primary infection; manifests as systemic illness with spirochetemia (disseminated rash, condylomata lata, lymphadenopathy, alopecia, hepatitis, glomerulonephritis)
• Latent syphilis: Patient has no clinical signs or symptoms of syphilis with serologic evidence of infection
• Early latent syphilis: Infection acquired within 12 months
• Late latent syphilis: Infection acquired more than 12 months ago
• Latent syphilis of unknown duration: Latent infection without clear timing of acquisition
• Tertiary syphilis: Late syphilis (acquired more than 12 months before diagnosis) with cardiovascular involvement or gummatous disease
• Neurosyphilis: Neurological manifestations that can occur at any stage of infection