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Lisa Villarroel, MD MPH
Medical Director, Division of Public Health Preparedness
Arizona Department of Health Services
Disclosures:
None
2
Fitzgerald TJ, Cleveland P, Johnson RC et al: Scanning electron microscopy of Treponema pallidum (Nichols strain) attached to cultured mammalian cells. J Bacteriol 130:1333, 1977.
PRIMARY
CDC Library
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CDC PHIL 16750
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CDC PHIL 12578
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CDC Library
PRIMARY SECONDARY
CDC Picture Cards
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CDC Library
PRIMARY SECONDARY
PRIMARY SECONDARYEARLY
LATENT
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PRIMARY SECONDARYEARLY
LATENTLATE
LATENT
PRIMARY SECONDARYEARLY
LATENTLATE
LATENT
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PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
CDC clinical slides
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
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NEUROSYPHILIS CAN OCCUR AT
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
TRANSMISSION TO THE FETUS CAN OCCUR AT ….
NEUROSYPHILIS CAN OCCUR AT
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CDC clinical slides
TRANSMISSION TO THE FETUS CAN OCCUR AT ….
CDC PHIL 16750
TRANSMISSION TO THE FETUS CAN OCCUR AT ….
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TRANSMISSION TO THE FETUS CAN OCCUR AT ….
TRANSMISSION TO THE FETUS CAN OCCUR AT ….
NEUROSYPHILIS CAN OCCUR AT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
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Credit: National Archives.
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
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PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
TRANSMISSION TO THE FETUS CAN OCCUR AT ….
NEUROSYPHILIS CAN OCCUR AT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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RA
TE
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MEN WHO HAVE SEX WITH MEN
MEN WHO HAVE SEX WITH WOMEN
PRIMARY & SECONDARY SYPHILIS CASES
MEN WHO HAVE SEX WITH MEN
WOMEN
MEN WHO HAVE SEX WITH WOMEN
PRIMARY & SECONDARY SYPHILIS CASES
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ARIZONA
U.S.
2007 2010 2013 2016
PRIMARY & SECONDARY SYPHILIS RATE / 100,000
2012 2013 2014 2015 2016
PRIMARY & SECONDARY SYPHILIS CASES IN ARIZONA
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2012 2013 2014 2015 2016
BLACK (24)
AMERICAN INDIAN
HISPANIC
WHITE
ASIAN (4.5)
PRIMARY & SECONDARY SYPHILIS RATE / 100,000
0
10
20
2012 2013 2014 2015 20160
15
30ARIZONA
CASE RATE
U.S. CASE RATE
CONGENITAL SYPHILIS CASES & RATES / 100,00
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PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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SYMPTOM RECOGNITION
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
PRIMARY
SYMPTOM RECOGNITION
SECONDARY TERTIARYEARLYLATENT
LATELATENT
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PRIMARY
SYMPTOM RECOGNITION
SECONDARY TERTIARYEARLYLATENT
LATELATENT
CDC Syphilis Images
PRIMARY
SYMPTOM RECOGNITION
SECONDARY TERTIARYEARLYLATENT
LATELATENT
Joe Engelman, SF City Clinic
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SYMPTOM RECOGNITION
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
SYMPTOM RECOGNITION
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
CDC Syphilis Images
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SYMPTOM RECOGNITION
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
CDC Syphilis Images
NEUROSYPHILIS CAN OCCUR AT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
Review of Ophthal,, 2008
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NEUROSYPHILIS CAN OCCUR AT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
Review of Ophthal,, 2008
SCREEN
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
25
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
LABORATORY TESTING
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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NONTREPONEMAL TESTS
RPR, VDRL
TREPONEMAL TESTS
TPPA, FTA-ABS
CIA, EIA (NEW)
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
YEARSWEEKS
TIME POST-INFECTIONTIME OF
INFECTION
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TREPONEMAL TESTS(TPPA, FTA-ABS)
WEEKS
TIME POST-INFECTIONTIME OF
INFECTION
YEARS
NONTREPONEMAL TESTS(RPR, VDRL)
TREPONEMAL TESTS(TPPA, FTA-ABS)
WEEKS
TIME POST-INFECTIONTIME OF
INFECTION
YEARS
UNTREATED
TREATED
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PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
NONTREPONEMAL TESTS
RPR, VDRL
FOLLOWS RESPONSE TO TREATMENT
1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024
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1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024
2-FOLD CHANGE
1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024
2-FOLD CHANGE
4-FOLD CHANGE [SIGNIFICANT]
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NONTREPONEMAL TESTS
RPR, VDRL
FOLLOWS RESPONSE TO TREATMENT
CAN VARY DAILY
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
NONTREPONEMAL TESTS
RPR, VDRL
FOLLOWS RESPONSE TO TREATMENT
CAN VARY DAILY
ARE FALSE POSITIVES
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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NONTREPONEMAL TESTS
RPR, VDRL
FOLLOWS RESPONSE TO TREATMENT
CAN VARY DAILY
ARE FALSE POSITIVES
ARE RARE FALSE NEGATIVES
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
TREPONEMAL TESTS
TPPA, FTA-ABS, CIA/EIA
.
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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TREPONEMAL TESTS
TPPA, FTA-ABS, CIA/EIA
.GOOD, EARLY PERFORMANCE
REACTIVITY PERSISTS OVER TIME
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
TREPONEMAL TESTS
TPPA, FTA-ABS, CIA/EIA
.GOOD, EARLY PERFORMANCE
REACTIVITY PERSISTS OVER TIME
LESS FALSE POSITIVES (FTA, EIA MAIN PROBLEM)
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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NONTREPONEMAL TESTS
RPR, VDRL
TREPONEMAL TESTS
TPPA, FTA-ABS, CIA/EIA
.
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
NONTREPONEMAL TESTS
RPR, VDRL
TREPONEMAL TESTS
TPPA, FTA-ABS, CIA/EIA
.
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
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Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
TREPONEMAL
Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
TREPONEMAL
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Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
REVERSE
Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
REVERSE
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Am J OB and GYN, April 2017
TRADITIONAL
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
NONTREPONEMAL (RPR)
REVERSE
Am J OB and GYN, April 2017
TRADITIONAL REVERSE
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
NONTREPONEMAL (RPR)
TREPONEMAL (TPPA)
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Am J OB and GYN, April 2017
TRADITIONAL REVERSE
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
NONTREPONEMAL (RPR)
TREPONEMAL (TPPA)
Am J OB and GYN, April 2017
TRADITIONAL REVERSE
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
NONTREPONEMAL (RPR)
TREPONEMAL (TPPA)
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Am J OB and GYN, April 2017
TRADITIONAL REVERSE
NONTREPONEMAL (RPR)
TREPONEMAL
TREPONEMAL (EIA/CIA)
NONTREPONEMAL (RPR)
TREPONEMAL (TPPA)
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
STAGING
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SYMPTOMS = PRIMARY / SECONDARY STAGES
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
NO SYMPTOMS = LATENT STAGES
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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NO SYMPTOMS = LATENT STAGES
EARLY IF IN PAST YEAR
NEG SYPHILIS SEROLOGY
KNOWN CONTACT TO EARLY CASE OF SYPHILIS
HISTORY OF SYMPTOMS
SUSTAINED 4x INCREASE
ONLY POSSIBLE EXPOSURE
LATE IF IN PAST YEAR
(NONE OF THOSE)
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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SYMPTOM RECOGNITION
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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SYMPTOM RECOGNITION
EMPIRICALLY TREAT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
SYMPTOM RECOGNITION
PARTNERS WITHIN 90 DAYS
EMPIRICALLYTREAT
EMPIRICALLY TREAT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
GET HISTORY
TREATMENT NEEDED?
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SYMPTOM RECOGNITION
PARTNERS WITHIN 90 DAYS
EMPIRICALLYTREAT
EMPIRICALLY TREAT
PRIMARY SECONDARY
GET HISTORY
TERTIARYEARLYLATENT
LATELATENT
TREATMENT NEEDED?
BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM
x 1, ONCE
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM
x 1, ONCE
BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM
x 3, Q WEEK
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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GET A TITER (REALLY).
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
GET A TITER (REALLY).
DAY OF TREATMENT CHECKLIST
DAY OF INITIAL LAB TEST DAY OF TREATMENT DAY OF FOLLOW UP
RPR 1:256 RPR 1:256RPR 1:1024
[NOT CHECKED]
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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GET A TITER (REALLY).
WARN ABOUT JARISCH-HERXHEIMER.
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
GET A TITER (REALLY).
WARN ABOUT JARISCH-HERXHEIMER.
COUNSEL NO SEX x 1 WEEK.
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
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GET A TITER (REALLY).
WARN ABOUT JARISCH-HERXHEIMER.
COUNSEL NO SEX x 1 WEEK.
ADVISE THAT ALL PARTNERS BE EVALUATED.
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
GET A TITER (REALLY).
WARN ABOUT JARISCH-HERXHEIMER.
COUNSEL NO SEX x 1 WEEK.
ADVISE THAT ALL PARTNERS BE EVALUATED.
CONFIRM HAS BEEN TESTED FOR HIV.
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
50
GET A TITER (REALLY).
WARN ABOUT JARISCH-HERXHEIMER.
COUNSEL NO SEX x 1 WEEK.
ADVISE THAT ALL PARTNERS BE EVALUATED.
CONFIRM HAS BEEN TESTED FOR HIV.
ESTABLISH FOLLOW-UP EXPECTATIONS.
DAY OF TREATMENT CHECKLIST
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
FOLLOW UP
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FOLLOW UP
SEROLOGIC TESTS ~Q6 MONTHS.
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
HIV (-) HIV (+)
PRIMARY / SECONDARY SYPHILIS
6, 12 MONTHS
3, 6, 9, 12, 24 MONTHS
EARLY LATENT / LATE LATENT SYPHILIS
6, 12, 24MONTHS
6, 12, 18, 24MONTHS
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
FOLLOW UP
SEROLOGIC TESTS ~Q6 MONTHS.
TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO.
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SEROLOGIC TESTS ~Q6 MONTHS.
TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO.
SUSPECTED TREATMENT FAILURE OR REINFECTION IF:
4-FOLD INCREASE IN TITERS
OR NEWLY SYMPTOMATIC
OR TITERS DON’T DECLINE
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
FOLLOW UP
SEROLOGIC TESTS ~Q6 MONTHS.
TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO.
SUSPECTED TREATMENT FAILURE OR REINFECTION IF:
4-FOLD INCREASE IN TITERS
OR NEWLY SYMPTOMATIC
OR TITERS DON’T DECLINE
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
FOLLOW UP
NEW HIV TEST? LP for CSF VDRL
? RETREAT (BICILLIN x3)
53
PRIMARY SECONDARY TERTIARYEARLYLATENT
LATELATENT
54
DATA
DATA PARTNERS
55
DATA PARTNERS POLICY
DATA PARTNERS POLICY ANSWERS
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DATA PARTNERS POLICY ANSWERS
DATA PARTNERS POLICY ANSWERS
CALL PUBLIC HEALTH
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.
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
.
PRIMARY SECONDARY TERTIARYEARLY
LATENTLATE
LATENT
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Joseph EngelmanKristen Herrick
Susan RobinsonStephanie Cohen
Laura DaltonPaul Bloomquist
CAPTCRoxanne Ereth
Rebecca ScrantonTymeckia KendallDon Herrington
ACKNOWLEDGEMENTS
59
EXTRA SLIDES
60
Rac Syphilis in Pregnancy OB GYN
61
62
STAGE STARTS LASTS (untreated) Other sxs Infectivity
Primary 10d‐12 weeks after inoculation (median time 21 d)
1‐6 weeks • Papule‐>Chancre• Nontender regional adenopathy
• Infectious by direct contact or blood
Secondary • 2‐8 weeks after chancre heals or
• 4‐8 weeks after onset of chancre
• can overlap with 1ary
“Several weeks” • symmetric, bilateral rash• mucous patches/condyloma lata• fever, headache, pharyngitis• hepatitis, osteitis,
glomerulonephritis• meningitis/ocular/oto‐
• Infectious by direct contact (when mucosal lesions present) or blood
Early Latent After resolution of 2ary symptoms
• Until 1 year after inoculation
• can alternate with2ary
• Neurologic: meningitis, ocular, oto‐, meningovascular (strokes)
• Infectious by direct contact (when mucosal lesions present) or blood
Late Latent 1 year after inoculation Until treatment or development of late symptomatic disease
• Infectious by blood
Late Symptomatic
15‐25 years after inoculation
Until treatment • General paresis (CNS parenchyma)
• Tabes dorsalis (posterior columns: sensory/proprio)
• Cardiac (aortitis, infarction)• Late benign (gummatous)
Ghanem. CNS Neuroscience & Therapeutics 2010;6(5): e157-68
63
“Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you.” – William Osler, 1909
“Syphilis… remains the despair of the statistician.” -- William Osler, 1917
“When it comes to syphilis, suspect your grandmother” – William Osler
“The souls of infants born only to die or suffer, cry out against the infamy of uncured syphilis.” – (well known venereal syphilologist)
“With our present appropriations, Federal and State and private, we might just as well try to empty the Pacific Ocean with a teaspoon.” – Dr. OC Wenger, 1926
![Ocular Syphilis, the Great MasqueraderDevelopment of a New Practice Model 1. [ ] References •Syphilis typically advances through four differentstages •Primary •Secondary •Latent](https://img.pdfslide.net/doc/110x75/5f7ecf4da3cb2c1bff201f51/ocular-syphilis-the-great-masquerader-development-of-a-new-practice-model-1-.jpg)
