[Question #2746] Oral syphilis
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94 months ago
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I am a 39 yo female. I have an 8 yo daughter. I fear her permanent teeth are notched. I had one act of unprotected fellatio performed in 1998 on a white male. No rash afterward but sore throat did occur about 3 months later. Eye floaters a few years later for which I saw 3 ophthalmologists and no mention of syphilis. I married and my husband and I were both virgins except for my one act of giving fellatio. I got pregnant at 30, 10 years after the fellatio. Had a negative RPR 2 times during my pregnancy. Daughter had no problems at birth but did have elevated liver enzymes at 6 yo for which she had a liver biopsy and no cause was found. No mention of syphilis from her doctor. I noticed the notched upper incisors and did online looking. I was worried that my RPR was false negative after 10 years during my pregnancy - I've read studies that show only 60-70% accuracy of this test in late stage. I had an FTA ABS done which was also negative, but it has now been 20 years. Could the Fta abs be false negative after 20 years? I also did a home test using Elisa and dried blood spot, but I don't know how accurate that collection method is. It was negative as well. What is the % risk I got syphilis from fellatio one time? In 1998, the female and male rates of syphilis were equal in my state, so not primarily in MSM at that time. Could my daughter have late congenital syphilis? Please help.
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Edward W. Hook M.D.
94 months ago
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Welcome to our Forum. I'll be glad to comment and, hopefully, to reassure you that neither you nor your daughter have syphilis. You are correct that among the findings reported to occur with congenital syphilis are notched teeth however your testing history provides complete assurance that you have never had syphilis. You are also correct that in persons who have had syphilis for decades, the RPR tests can go negative but even when this occurs, the FTA tests remain positive for life except in the tiny proportion of persons with primary (1rst stage syphilis) who are treated within a week or two of infection. In these latter cases, the disease is absolutely cured and there is no risk to children born to mothers who had syphilis. Thus your negative FTA test, even now, years after your pre-marital exposure, proves that you have never had syphilis.
I should add that oral syphilis is an extraordinarily uncommon site for syphilis to occur, even among person who practice oral sex regularly with high risk partners.
I am certainly no a specialist on the causes of notched teeth but in your case, I can assure you that congenital syphilis is not the cause of your daughter's problems. I hope my comments are helpful and reassuring to you. EWH
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94 months ago
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What about the Chicago study where 20% of syphilis-diagnosed patients (MSM) reported only oral exposure? There was also a Manchester study in England that showed even higher rates from oral. Do you know a percent risk per act of oral syphilis? I've also read that Fta abs is about 94.5% sensitive in late untreated syphilis. Have you found this to be true? Peterman did a study in 2013 entitled "Do women with persistently negative RPR's vertically transmit?" It couldn't find convincing evidence of this. Would an ophthalmologist easily see signs of syphilis on a dilated eye exam? Thank you so much.
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Edward W. Hook M.D.
94 months ago
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The problem with the internet is that low quality studies and case reports are presented with equal weight to carefully performed, well controlled research studies which take into count confounding factors the impact the presentations and test results. Having studies this disease for over 30 years and written over 53 research papers on the topic, I am confident that the reports from Chicago are not representative of the way most people get this infection, not to mention that virtually all of the patients in the Chicago report were men who had sex with men, not heterosexual women. Tom Peterman is a friend and a colleague as well as a careful and thoughtful investigator. You asked for my assessment and I provided it and am confident when I told you that there was no evidence or reason for you to worry that you had gotten syphilis, much less given it to your daughter. Whether you believe me or not is, of course, up to you. If your daughter had congenital syphilis, I can assure you that a treponemal syphilis blood test would be positive (in both of you) and you could prove that syphilis is not a concern by having her tested. Personally however, I see no reason for this.
Yes, on ophthalmologist would see syphilitic eye disease if present.
I'm not trying to be unkind here. I appreciate your concern for your daughter. I also am confident when I say that there is no reason for you to worry that you acquired syphilis from your single premarital exposure and, likewise, you did not infect your daughter. If anything, your focus on syphilis has the potential to hinder you from finding any problem that might truly be there. I hope this is helpful. Really. EWH
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94 months ago
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Just to clarify:
1) my tests are 100% definitive that I have never had syphilis?
2) why is the RPR even used in pregnancy if it's not sensitive in later stages? Is this because most women don't vertically transmit in later stages?
3) is late congenital syphilis seen very often in the us?
4) are the tppa or newer eia tests better than fta abs for detecting late syphilis?
Thanks in advance for your advice. It means a lot.
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Edward W. Hook M.D.
94 months ago
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Straight to your questions:
1) my tests are 100% definitive that I have never had syphilis?
Correct
2) why is the RPR even used in pregnancy if it's not sensitive in later stages? Is this because most women don't vertically transmit in later stages?
In some settings the more sensitive (for past and present) treponemal EIA tests are now used for syphilis testing but it really does not matter in your case as the RPR would virtually always be positive in syphilis which is infectious to others.
3) is late congenital syphilis seen very often in the us?
No, in 2009 which I estimate was the date of your daughter's birth, there were 431 cases of congenital syphilis is the U.S. population of over 300,000,000 people. Last year that number increased to 628 (a big increase but still numerically very few). Nearly all of these cases were early congenital syphilis.
4) are the tppa or newer eia tests better than fta abs for detecting late syphilis?
Better? They are more likely to detect current or past syphilis. Most of the additional positive tests detected by the EIA tests represent old, treated, non-infectious syphilis. The EIA tests are at least as sensitive as the TPPA and FTA tests.
I hope these answers are helpful. This is my third and therefore final reply and the thread will be closed later today. In closing let me tell you that I am not a betting person but i would bet my home that you did not acquire syphilis at your single act of fellatio in 1998 and that your daughter does not have congenital syphilis. I hope my comments will help you to move on. EWH