[Question #4328] Syphilis Exposure

29 months ago
One week ago I had unprotected, insertive anal and oral sex with another male. I did not ejaculate inside him. I did not perform any oral sex of any kind on him. I did not see any lesions or rashes.

This morning he informed me that he tested positive this week for gonorrhea and syphilis and was treated with shots.

I tested positive once for gonorrhea and symptoms manifested within 36 hours of exposure, so I presume I am not asymptomatic.

My questions:
1. Should I be treated for syphilis presumptively? I read accurate test results are not likely within one week of exposure.
2. I had a mild allergy to penicillin as a child and 10 years ago had a mild reaction to a skin prick test. Does that complicate treatment?

I have no idea what the risk profile is under the circumstances, but I presume he could have had a lesion that was internal and not visible.  Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Welcome to the forum. Thanks for your question, which addresses a very common situation and some basic (and very important) principles of STD prevention.

Just to be clear, it sounds like the timing was that your partner had not been diagnosed or treated before your sexual contact with him. If he had been treated before then -- even as little as several hours and certainly if more than a day -- then he was non-infectious for both gonorrhea and syphilis. In that event, you'd have to look for other sources for your gonorrhea. However, it seems you definitely caught the gonorrhea from him, right?

The word "asymptomatic" means exactly that: if there are symptoms, it's not asymptomatic. Presumably you had urethral discharge, and maybe painful urination? 36 hours is very quick -- it usually takes longer, like 2-5 days. So again this raises the possibility you had been exposed to gonorrhea in an earlier exposure. But 36 hr is possible. Anyway, I'm glad you were treated.

To your specific questions:

1) Whether you should be treated presumptively for syphilis depends on the stage of your partner's syphilis. If he had symptoms of early syphilis (the sore, or "chancre", of primary syphilis, or a skin rash of secondary syphiils), you definitely should have been treated for syphilis yourself, without waiting for test results. Same thing if your partner didn't have symptoms but was suspected to have syphilis of less than a year in duration, or if duration was unknown. Indeed, I'm surprised you were not treated by the clinic or doctor who treated your gonorrhea. However, if your partner was believed to have syphilis more than a year in duration, treatment isn't necessarily automatic. (But perhaps they were concerned about your penicillin allergy? More about that below.)

FYI, the standard treatments for gonorrhea -- a shot of ceftriaxone, plus a single dose of azithromycin by mouth -- would be likely to abort incubating syphilis. So perhaps that was thought to be adequate. Still, standard practice would have been an injection of long-acting penicillin (benzathine penicillin, Bicillin) for syphilis.

2) Your past penicillin allergy is an issue, but probably not a serious one. The large majority of people with histories of childhood penicillin allergy outgrow it and can safely be treated with the drug. But many physicians would still avoid penicillin -- especially a long acting version that cannot be removed once injected. An alternative to Bicillin is 2 weeks of doxycycline by mouth. OTOH, perhaps your doctor decided to rely on the ceftriaxone and azithromycin, if that's how your gonorrhea was treated. Either way, you'll need to have regular follow-up including a syphilis blood test in a month and perhaps 3 months, and should avoid sex with new, unexposed partners for a few weeks.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD

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29 months ago
Thanks Dr. Handsfield,

I was the one that was unclear. Sorry about that. My sexual partner did not test positive until after our encounter.

I was not treated for gonorrhea or for anything else this week. I was only informed this morning of his diagnoses and treatment. I am not symptomatic with gonorrhea at this time. I only mentioned it because I know that the one time I was infected with gonorrhea, approximately two years ago, I had symptoms within a day or two, so I assumed if I had contracted it 7 days ago, I would have had symptoms.

My partner had no active symptoms of syphilis but tested positive and was treated this week, on the same day he tested positive. Based on his prior testing, he likely had syphilis for less than a year in duration.

Regarding penicillin, if it is the most effective treatment, I'm willing to risk a slight reaction. I do not believe, though I have no foundation for this, that I would suffer anaphylaxis.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
OK, thanks for the clarifications. You clearly need treatment for gonorrhea -- don't wait for symptoms or a positive test result. However, all potentially exposed anatomic sites should be tested. By "exposed" I mean with anyone in the past couple of weeks, not just this partner. Most men who have sex with men should be tested at all 3 areas in this situation, i.e. rectal and throat swabs and urine (or urethral swab), then treated with ceftriaxone plus azithromycin.

As I said above, this is a borderline situation for syphilis treatment. Ideally, add benzathine penicillin to the above situation. However, ceftriaxone plus azithro usually would be sufficient. Discuss pros and cons with the clinic or doctor you see. If you're in a metropolitan area with a public health STD clinic, that would be the ideal place. Or whatever clinic diagnosed and treated your partner.
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
FYI, I ran this by Dr. Hook. Here is what we together would recommend, for you to discuss with the doctor or clinic you see:  preventive treatment for gonorrhea, as above; and a syphilis blood test. If your blood test is negative, it should be OK to NOT give the benzathine penicillin, then do another syphilis blood test in a few weeks. If still negative, nothing more need be done. If the test is positive, it would mean you were infected before the exposure above and you would definitely need penicillin.

It would still be an option to treat now with penicillin as preventive treatment for syphilis.  It is unlikely you would have any kind of serious reaction. But if you do, management could be difficult, and in theory this could be quite dangerous. Once the shot is given, you'll have penicillin in your system for 2-3 weeks.

As above, all this should be discussed with the doctor/clinic and let them make the final decision or recommendation.
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29 months ago
Thanks.

I started doxycycline this afternoon. When I see my PCP tomorrow, I will start the treatment for gonorrhea.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
That should work, but perhaps not necessary. And it will screw up gonorrhea testing. Don't take it (or any more doses) until you see your PCP. There's not that much hurry.

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29 months ago
Roger that, Dr. Handsfield. Thanks.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Finally, if your doctor agrees to the plan for doxycycline to prevent syphilis, you won't need the azithromycin. Ceftriaxone plus doxy is just as good (perhaps slightly better) against gonorrhea than cef + azithro.

That normally would conclude this thread, but I'll leave it open in case there are any final questions after you have seen your doctor. But I won't have anything more to say until then.
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29 months ago
Negative results on a full panel. But my PCP administered the Ceftriaxone and told me to continue the doxy. Thanks for your help, Dr Handsfield
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
29 months ago
Sounds good. Thanks for the thanks; I'm glad to have helped.---