[Question #5501] Syphilis presumptive therapy?

20 months ago

Dear  Doctors,

I’m a 72 y.o. MD ( Internal Medicine ) from Italy. On the 20th of May ( 19 days ago ) I had an encounter with a 45 y.o.  Italian CSW .  We performed a brief condom protected fellatio and subsequently engaged in protected  insertive vaginal sex . At the beginning the condom slipped off to the floor. I’ m not sure if there was a real penetration , is possible that a brief contact  ( 10-30 sec.s ) between external genitals occurred. Wearing another condom we ended up with a vaginal intercourse . Due to  the 1st condom problem I asked her to check for HIV and syphilis. The HIV1-2  test ( fourth generation Ag p24 Ab ) turned out to be negative , VDRL qualitative positive, TPHA quantitative positive ( 1:180 ) .The laboratory states : negative < 1:80 , positive > 1:80 .

The lady denies previous STD including syphilis , she assures engages only in protected ( male condom ) sex.

Now questions.

As far as HIV risk  I’m  fairly positive ( low risk activity , negativity of the her test also considering the window period ) . I’ ll perform the duo test at 4 weeks .

Syphilis.

I don’t have any sign of changes whatsoever in the penis, scrotum and pubic area . No general symptoms at all besides anxiety.  I had just one vaginal intercourse with my wife on the 3rd of June,  9 days after the  case ( at that time I had only the report of HIV test ) .

Should I wait to six weeks and perform VDRL and TPHA or , as I read on CDC 2015 guidelines “ Persons who have had sexual contact with a person who receives a diagnosis of primary, secondary, or early latent syphilis within 90 days preceding the diagnosis should be treated presumptively for early syphilis, even if serologic test results are negative.”

                Should I initiate therapy with benzatin penicillin 2.4 million once ( I’ m not allergic to penicillin ) and in that case this “ presumtive therapy “ could invalidate subsequent serological tests ? Most of all I want to spare my wife any risk and possibly any need of testing or therapy and solve the case ASAP with a shot of penicillin if necessesary.

Thank you for yor help and congratulations for your outstanding service.

Elias

Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
Welcome to our Forum.  Thanks for your confidence in our service.  I'll be glad to comment.  To summarize, you had a mostly protected exposure to a commercial sex worker about 19 days ago however because of the potential of superficial contact without a condom in place, you had her get tested.  Her HIV combination antigen/antibody test was negative but both her VDRL and TPHA tests were positive indicating that she has or has had syphilis in the past.  Given her statement that she has not had syphilis, she should be approached as though she has active syphilis.  She needs to be treated for syphilis and while you may not develop syphilis, your situation is one for which preventative therapy is recommended.  IF you were exposed  to a lesion that she was unaware of, the literature suggests that there is about a 33% chance of you acquiring infection and developing a positive blood test over the next up to 90 days (i.e., a negative test at 19 days is not sufficient to be sure that you were not infected).  The possibility of infection can be prevented entirely with prophylactic therapy. Your safest course of action is to get treated at this time with a single injection of 2.4 million units of benzathine penicillin to prevent the development of active syphilis.  This sort of preventative therapy is, for all practical purposes, 100% effective and after receipt of penicillin, there is no need for further blood tests.

I hope that this information is helpful to you.  If any part of this reply is unclear, please use your up to two f/u questions to seek clarification.  EWH
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20 months ago
Hello Dr Hook, thank you for your prompt reply . I' ll follow your advice and get the benzathine penicillin 2.4 million dose ( two 1.2 million doses in two days would be OK as well ? ) . Some comments and questions. First of all by mistake I indicated the TPHA titer to be 1:180 , it was 1:160 indeed (  that doesn't change anything  I suppose ) . The superficial contact was brief indeed and maybe the CSW was reluctant to admit previous ( and maybe treated ) syphilis . Moreover the fact that after 20 days no local sign of disease is evident could mean that the risk of trasmission has been low , but of course I don't want take any risk. 
Questions.
1. I didn' t have any blood test so far, do you think it would be advisable to be tested in the future ( let's say 90 days ) and the prophylactic therapy could interfere with the test?
2. Should my wife be tested or treated  ( that would be embarassing of course ) ? As I wrote I had only one vaginal intercourse with my wife 9 days after the  contact at risk,  and beeing completely free of genital lesions I suppose that even if I got the disease the trasmission should not be possible in that situation. I'm aware that 7 days post therapy I can resume a regular sexual activity .
3. As far as HIV do you suggest to be tested ( at 4-6 weeks with the antigen antibody test ) ? At that time could be worthwhile test also for syphilis  ?
Thank you again,
Elias

20 months ago
Hello Dr. Hook,
this is to inform you that I'm having difficulties in finding the benzathine penicilline ( asked in several pharmacies in different cities ) . Maybe the drug can be ordered but I don't  know  when it will be available . Driven by impending anxiety  I' ve decided to start with doxyciclin  100 mg. bid x 14 days.  Of course I' m ready to change the treatment plan ( just one pill assumed so far ) on the basis of your advice . Thank you again.
20 months ago
Hello Dr. Hook, finally I've found the benzathine penicilline 2.4 and I'll have the injection tomorrow. I don't think one pill of doxycicline I assumed today will interfere but for sure your opinion is mostly welcomed.  Sorry for the many questions, thank you .
Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
 For the follow up information. I'm glad you were able to find the benzathine penicillin. Please take it all on the same day.  

 You are correct, the difference in TPHA titers does not change my assessment or recommendation. Regarding your specific questions :

1.   The prophylactic therapy will not interfere with your blood test in any way. The importance of the blood test is less for you than for your wife. Whether or not your blood test is positive the benzathine penicillin will be curative. On the other hand, if your blood test is negative there is no risk to your wife  and no reason for her to be treated. If your blood test were positive however it would be important for her to receive preventative therapy as well. 

2.   I believe I have answered this question above. 

3.   I see no reason for you to need HIV testing. Your partner was tested and was negative and your exposure was affectively a no risk event. Similarly, if you test for syphilis in the next day or two and the test is negative, there is no reason for follow-up testing following your penicillin therapy.
 
 I hope I have addressed your follow-up questions. If I missed one please don't hesitate to let me know. EWH 

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20 months ago
Hello Dr. Hook sorry for asking 
a clarification . I understand that my blood test is important in deciding to treat or not my wife. At which test you refer ( VDRL, TPHA or both ) And WHEN should I be tested? At 6 weeks would it be definitive as I read in several answers to similar questions ? Or should I be tested later on if negative?
Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
No problem.  if your test has turned positive, both tests should be positive but my preference would be to test with the VDRL or RPR at this time as explained above.  if one of those tests is negative, I would not do a TPHA and would not feel a need  for follow-up testing of any sort.  No need for additional testing at six weeks or at any time related to this encounter.  

This is the 3rd response to this set of questions.  Thus, as per Forum Guidelines, the thread will now be closed without further replies.  Take care.  EWH
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