Introduction

All patients diagnosed with Syphilis should be given a detailed explanation of their condition and this should be reinforced with the offer of written information.

Syphilis in Pregnancy
Refer to BASHH Guideline on Syphilis (beyond the scope of this document)

History taking and Surveillance
Major outbreaks of syphilis (mostly in MSM) have been reported in London, Manchester, Brighton and Dublin as well as Glasgow and Edinburgh. Ask about sex in scene venues (saunas, back rooms) and geographical location of sex partners. Record this location in the notes.

There have also been recent outbreaks of syphilis affecting young heterosexual males and females in Scotland.

A national surveillance scheme exists for all early infectious syphilis. This uses laboratory data and clinician-initiated reports. Each clinic should be aware who completes these forms in their area. These forms should be completed proactively. Completion of this form should be recorded in the patient clinical notes.

Clinical and laboratory assessment:

• Testing for Syphilis always involves blood tests. In addition if there are suspicious lesions then dark ground microscopy and PCR should be performed where possible (see under primary syphilis).
• Blood tests for syphilis are either known as ‘Treponemal’ or ‘non-treponemal’
  tests for syphilis:
  • Treponemal tests include TPPA, Treponemal total antibody EIA and Inno-LIA. These should not be used to assess disease activity and remain positive for life in most patients.
  • Non-treponemal tests include VDRL and RPR and are quantitative. They are important for monitoring response to treatment and possible reinfection.
• The initial screening test is a Treponemal total antibody EIA. If the screening test is found to be positive, further tests will be required and requested. These may include VDRL/ RPR, TPPA, Inno-LIA blot and specific IgM. These tests may be done locally or sent to the regional virus laboratory, Glasgow Royal
  Infirmary or The Royal Infirmary of Edinburgh Microbiology/Virology Lab or Colindale.
• Inno-LIA blot is recommended when the confirmatory test does not confirm the positive treponemal screening test result.
• All positive tests should be repeated on a second specimen for confirmation
• If syphilis is suspected clinically, indicate this clearly on the request form
• Full clinical examination, with particular emphasis on the skin, genitals, lymph nodes and mucosa is essential in all patients found to have positive syphilis serology. Cardiovascular and neurological examination is required in late syphilis and in those with relevant symptoms.
• HIV testing should be recommended to all patients diagnosed with syphilis.
• A full STI screen should be recommended to all patients diagnosed with syphilis. In addition the need for Hepatitis B vaccination should be assessed.
• It is important that on the very first day of of treatment (DAY 1 of treatment), VDRL/RPR titre is taken, allowing accurate assessment of response to treatment. It is also important to ensure that when assessing response to therapy, results being compared are from the same lab.

HIV infection and Syphilis

• Serological tests for syphilis in patients with both syphilis and HIV are generally reliable although false negative tests and delayed appearance of sero-reactivity have been reported.
• HIV infected patients with early syphilis may be more likely to develop multiple/ large or deeper genital ulcers.
• HIV infected patients with early syphilis may have an increased risk of neurological involvement, unusual neurological manifestations, and higher rate of treatment failure.
• HIV infected patients may have neurological abnormalities that may be difficult to differentiate from neurosyphilis. Limited case review data suggests higher risk of neurosyphilis in HIV+ if VDRL/RPR 1:32 or greater.
• A lumbar puncture is recommended in all HIV positive patients with:
  • Serological treatment failure
  • Neurological or ophthalmological signs/ symptoms
  • VDRL/RPR 1:32 or greater at any stage
  • Consider in those with late syphilis and CD4<350
• HIV infected patients may also be more likely to have rapid progression to gummatous syphilis
• All HIV infected patients co-infected with syphilis should have the choice to have a neurosyphilis treatment course whatever their syphilis infection stage. The decision may involve their attitude to further complications, injection discomfort and the likely ease of follow up. These difficult treatment decisions must be made by a senior HIV-experienced doctor
• HIV infected patients may have a slower rate of decline of VDRL/ RPR after treatment
• HIV co-infected patients should be followed up for life with at least six monthly serology (consider 3-monthly in an outbreak situation)