Dear  Doctors,

I’m a 72 y.o. MD ( Internal Medicine ) from Italy. On the 20^th 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 1^st 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 3^rd 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

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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. 

Hello Dr. Hook,

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 .

 For the follow up information. I'm glad you were able to find the benzathine penicillin. Please take it all on the same day.  ---

Hello Dr. Hook sorry for asking 

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