Late Latent Syphilis

Syphilis serology is positive, patient is asymptomatic and has no known negative serology within the last 2 years.

See below for investigations required.

Examination

• All patients need a careful clinical cardiovascular and neurological history recorded in the notes.
• Auscultation must be performed in patients with late latent or tertiary syphilis.
• Patients who have signs or symptoms of cardiovascular involvement should have a full cardiovascular assessment. Consider an echocardiogram +/- chest x-ray before starting therapy to exclude aortic valve disease. Patients with clinical or radiological evidence of aortic valve disease must be referred to a cardiologist for further assessment.
• Patients should have a thorough neurological examination if they have symptoms suggestive of neurological involvement
• The BASHH 2015 guidelines discuss the necessity of CSF examination in asymptomatic patients. Asymptomatic patients with no clinical findings consistent with neuro-syphilis do not need a lumber puncture. CSF examination should be done in those who have:
  • Neurological/opthalmological signs/symptoms
  • VDRL/RPR 1:32 or greater
  • Those with treatment failure

There is much less urgency in treating late syphilis and it is better to plan treatment so that it can be reliably completed

**Benzathine penicillin G 2.4 MU intramuscular on day 1 & 8 & 15
(as Extencilline 8ml) (NB unlicensed medication, named patient form may be needed)
For administration, see Preparation Instructions for Extencilline 2.4MU
OR
**Procaine penicillin 600,000units intramuscular once daily for 14 days
(**unlicensed medications, named patient form may be needed)
PENICILLIN ALLERGIC (or declines parenteral):
Doxycycline 100mg twice daily orally for 28 days

• Jarisch Herxheimer reaction is less common than in early syphilis
• Procaine reaction. This is caused by inadvertent IV injection of procaine penicillin which is minimised by the aspiration technique of injection. Lasts for less than 20 minutes and is characterised by feelings of impending death +/- seizures. Anaphylaxis should be excluded and the patient should be reassured and calmed. Sedation may be required for seizures.
• Anaphylaxis – facilities for resuscitation must be present. Refer to local policy for further guidance

Patients should remain on the premises for 15 minutes after receiving their 1st injection to allow observation for immediate adverse reactions.

Partner Notification 

• All patients to see sexual health adviser

Follow-up

• 4 weeks after end of treatment regime - to check compliance and partner notification
• 3 months - to repeat serology ± HIV test
• VDRL/RPR is often negative in late syphilis but this does not exclude the need for treatment. Follow up is to ensure adherence and for completion of partner notification. Discharge at 3 months if VDRL/RPR remains negative.
• If VDRL/RPR titre was raised prior to treatment, repeat at 3,6,12 months until VDRL/RPR negative or reduced and serologically stable on two occasions.
• Ask permission to write to GP to confirm treatment complete, give patient a written summary of treatment with discharge serology