[Question #5217] Follow-up to #5163 - Syphilis testing/symptoms

24 months ago
I just wanted to follow up on my prior question. To summarize: unprotected oral sex with CSW on Feb 2, appearance of penile ulcer on March 9 (34 days later) with accompanying pain in groin/upper thigh area, both resolved in ~10 days. I had non-reactive RPR and TPPA tests on March 11 (two days after noticing the ulcer; 36 after encounter), and non-reactive RPR and Syphilis Health Check on March 20 (11 days after noticing the ulcer, 45 days after encounter). On the March 20 visit to the STI clinic they also sent a sample to the state lab for TPPA test. I returned to the STI clinic yesterday for a two-week follow-up. They told me the state lab refused to do the TPPA test because of the prior RPR/SHC being non-reactive and that they couldn't do more blood tests either. 

I appreciate and understand your prior response and I was hoping to have that confirmed by the TPPA test that was refused by the state lab. Therefore, my questions are: 
(1) Whether you feel that further testing is clinically necessary (setting aside my obvious anxiety about the situation)? 
(2) Yesterday, the APRN told me that a blood test like the Syphilis Health Check would likely be positive a week after a chancre appeared because a chancre itself indicates that the body has developed detectable antibodies, what's your opinion on that point? 
(3) Since I continue to be concerned that essentially I experienced "classic" symptoms of primary syphilis (chancre+pain in inguinal lymph nodes) is it at all possible that I have simply had all of these blood tests performed too early (even though RPR and SHC were 10 days after appearance of possible chancre)?

I am simply trying to determine my best path forward at this point. I don't want to do additional testing if I'm for sure in the clear already, but if further testing is clinically still relevant I'll gladly do it (assuming it will be conclusive at this point).

Thank you in advance for engaging again. Sincerely appreciated.
Edward W. Hook M.D.
Edward W. Hook M.D.
24 months ago
Welcome back to the Forum.  I'm sorry that you continue to worry about the virtually no risk for syphilis that we interacted about earlier.  I can assure you that my opinion has not changed.  You did not acquire syphilis from the exposure you described.  Let's go straight to your questions:

1.  I agree with the folks at the clinic. There is certainly no clinical reason for additional testing.
2.  I agree.  If your genital lesion had been syphilis, subsequent syphilis blood tests, including the Syphilis Health Check would have been positive.
3.  No

I really see no reason for additional testing.  I tried to indicate that earlier.  My opinion has not changed.  EWH
24 months ago
Thank you, Dr. Hook. That is reassuring.

Can you explain something to me about the production of antibodies and their possible detection by blood tests? You and Dr. Handsfield indicate that 6 weeks from exposure is typically conclusive. In a prior response on this forum, Dr. Handsfield explained that "Untreated primary syphilis typically lasts 3-4 weeks, from onset of the chancre, usually 10-20 days after exposure, until it heals. The RPR is increasingly positive during that time. In patients with primary syphilis only 2-3 days duration, RPR is positive in less than half. By the time the chancre clears up, it's 100%. If you average everybody with primary syphilis, depending on when they are tested, about 25% have negative results. All those are in patients tested earlier than 2-3 weeks after exposure. Everybody with new syphilis has a positive RPR by 6 weeks."

Obviously, I was tested negative on RPR and SHC at 6.5 weeks, but since my lesion appeared only 1.5 weeks prior to that I'm just trying to understand how that plays into the timeline Dr. Handsfield described above. 
(1) Does the antibody production basically start at the time of inoculation, thereby providing the basis for the statement that "everybody with new syphilis has a positive RPR by 6 weeks"? '
(2) And in that case could I possibly have tested positive in, say, week 4 before the lesion appeared? (i.e. are antibody detection/production essentially unrelated to timing of a chancre?
(3) Or, is the appearance of a lesion the initial manifestation of the early stages of antibody production, which supports the notion that someone could be nonreactive in the early stages of a legion even if that legion appears as late as five weeks after inoculation
(4) You asked in our prior exchange if I had taken antibiotics at any point after the encounter. I didn't take antibiotics, just some topical Lotrimin Ultra (Butenafine hydrochloride) for jock itch, which I believe is just an antifungal. I assume that has no impact?
(5) You mentioned previously that oral syphilis is very rare in any event. The APRN suggested that oral lesions in secondary syphilis are not that uncommon and highly infectious. What's your opinion on that?

I really do apologize for the additional questions. I understand the low-risk nature of my exposure! I appreciate everything that you have said so far. As you can tell, I am just having a hard time convincing myself that I am really in the clear given the symptoms I experienced and the fact that my lesion appeared later than "average" (and therefore whether everything else is delayed as a result).  Thank you.

Edward W. Hook M.D.
Edward W. Hook M.D.
24 months ago
Sigh.  I wish you would accept the assessments you have received.  Clearly you are overthinking this.  Please realize that all timelines provided represent a range, not absolute values.  Straight to your questions for brief answers:

1.  The presence of the syphilis bacteria (Treponema pallidum) elicits an antibody response. that response takes a variable period to occur.  Similarly, the time from acquisition of infection to development of a lesion varied.  Irrespective however, one the organism is present and detect by the immune system, the process of antibody production begins even though it may take a while for those antibodies to be detectable. 
2.  This is a "what if" question which serves no purpose.  Anything is possible.  Aliens could invade the earth tonight.  
3.  No antibody production can occur before a lesion appears.  See my initial comment.
4.  You assume correctly,.  Lotramin is an antifungal drug with no activity against syphilis.
5.  Note sure what the APRN is but they are wrong or you are misinterpreting what they have said. 


23 months ago
Thank you for your response. I had further tests last week (9 weeks from exposure; 4 from onset of ulcer.) RPR and TPPA, both non-reactive. 

As you can tell, I am having difficulty attributing my symptoms to something else, mostly because I am still experiencing pain in the area of my inguinal lymph nodes, either side of my testicles and sometimes above them in my very lower torso.

(1) Have you ever seen a patient or heard of one who tested negative on RPR/TPPA at 9 weeks from exposure and who subsequently tested positive? I know you described the 3 month/12 week standard recommended by CDC and many others as overly conservative, but I'm finding it hard to not think that I might be just slow in developing detectable antibodies given that I continue to experience inguinal pain. (If answer is "no", what's the purpose of the 3 month window?)
(2) What about someone who tested negative on RPR/TPPA three weeks after chancre was gone?
(3) What type of inguinal lymph node symptoms are typical in syphilis (i.e. visibly enlarged nodes? nodes you can feel with your fingers? is pain even an indicator? Some sources say non-painful, others say painful.  I get sporadic (but certainly daily pains) in the areas described above. 

I apologize again for the extra questions. In my defense, though, unlike many people who post here who have no symptoms after an encounter, I have experienced at least two symptoms of primary syphilis (possible chancre and lymph node pain). If I had not and was not experiencing those things I would certainly accept a 6 week blood test as conclusive. It is only the presence of possible symptoms that is causing me to question the blood test results. I had never had an encounter like this before (with a csw) and then within 5 weeks I have a penile sore (for the first time ever) and lymph node pain (for the first time ever). I hope you can understand why I am concerned. Those symptoms seem to outweigh the "low risk" nature of my exposure.

(4) Should the fact that I have had symptoms and still tested negative make me more confident in the blood results, or do the presence of symptoms make me a (rare) candidate who should test again at 12 weeks to be certain?
(5) With all that being said, should I have any concerns at all (even <1%) about resuming unprotected sex with my girlfriend at this time, or should I wait until a 12 week test?

Thank you again for you time. Very much appreciated.
Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
Sigh. I am sorry you cannot give up on the idea that you have syphilis.  Your tests PROVE that this is not the case.  Having tried to reason with you unsuccessfully, I  guess we will need to agree to disagree.  Further testing is NOT going to change the test results, nor is it going to change my assessment.  I publish research on syphilis, write text book chapters on the topic and am asked questions about this disease by doctors on a regular basis, all of whom appear to believe my advice. Of course none of that means you need to agree but I do need to point out that asking "What if" and "Have you ever" questions is not going to change my assessment of advice. Presuming your tests were done in a qualified la (I'm sure they were), I will have nothing more to say. You can continue to buy into the misinformation which you have apparently gotten from the internet- up to you but please do not return to this forum with further questions of this sort- they will not help you and they will not help others who read posts on our site to learn what expert think about their problems.  In answer to your specific questions and as a final reply to your questions:

1.  No!
2.  No!
3.  Painless swollen nodes.  This however is not particularly suggestive of syphilis.  Swollen inguinal lymph nodes are a non-specific finding.  
4.  YES!  the presence of symptoms and subsequent  negative blood test should ABSOUTELY be accepted as PROOF that you do not hav syphilis!
5.No, there is absolutely no reason to avoid unprotected sex with your GF.

End of thread. EWH