Pediatric emergency medicine trisk 2348 2348
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or the infant with any symptoms consistent with congenital syphilis and positive
serologic tests for syphilis, should be managed as a presumptive case.
The treatment of choice for syphilis and the only accepted regimen for
pregnant women is penicillin. Treatment recommendations are summarized in
e-Table 94.32 . Treatment for nonpregnant adolescents and adults who are
penicillin-allergic is doxycycline 100 mg twice daily for 14 days for primary,
secondary, or early latent syphilis and for 4 weeks for late latent or latent syphilis
of unknown duration. Contact precautions should be used for infants with
congenital syphilis, as nasal secretions and dermatologic manifestations are
heavily laden with spirochetes for up to 24 hours after completion of therapy.
Syphilis, Acquired
Acquired syphilis is stratified into stages based on clinical manifestations and
serologic findings. The clinical and laboratory findings present at different stages
are summarized in
e-Table 94.33 , and the treatment recommendations by
stage are reviewed in
e-Table 94.32 . One cause of confusion relates to
serologic testing for syphilis. Two broad categories of tests exist. The first test
developed were nontreponemal tests, which measure primarily IgG. These
include the rapid plasma reagin (RPR) and the venereal disease research
laboratory (VDRL); the former is a serum test, the latter performed on CSF.
These tests have the advantage of being inexpensive (optimal for screening tests)
and decreasing in response to therapy, allowing for serial monitoring. These tests
have disadvantages including false-positive results, which have been best
described in patients with anticardiolipin antibody, autoimmune disease, HIV
infection, and pregnancy; and false-negative results in some patients with
secondary syphilis and in many patients with late-stage syphilis. The second
class is treponemal tests. These include the FTA-ABS (fluorescent treponemal
antibody absorption), MHA-TP (microhemagglutination test for antibodies to
Treponema pallidum), and the TP-PA (Treponema pallidum particle
agglutination). These tests are confirmatory assays when nontreponemal tests are
positive, and also are useful in the diagnosis of late stages of syphilis. They are
as sensitive as nontreponemal tests for late disease, and are much more specific.
These tests cannot be used to monitor response to therapy, as they do not revert
to negative with therapy. All patients with syphilis should be screened for HIV
and other STIs. Contact precautions should be used for any syphilis patient with
open lesions or secretions.
Suggested Readings and Key References
