[Question #5734] Syphilis

21 months ago

Hello Doctor.  I hope you can help me with my situation. 

I am a straight male and on May 11th of this year I met up with a guy from Grindr. I did not know him prior to this. We engaged in oral sex, I received a blowjob from him and I rimmed him for less than 10 seconds. It all happened so fast that I didn’t check his anus for any marks or Lesions. Overall, the encounter lasted around 5 minutes. For the first two weeks, my anxiety was through the roof. I contacted him and asked him if he was negative for any std’s (which I should’ve done prior to the encounter) and he told me me that he had recently been tested for std’s and was negative. He also mentioned that he was on prep. I can’t be too sure that he was being completely honest. I don’t engage in random hookups as I have been in a relationship with my girlfriend for the past three years. I went to see the doctor on May 24th, which was 13 days after the possible exposure. Prior to the appointment, I had no visible symptoms on my genitals or anywhere on my body. I was only experiencing, nausea, loose stools, and I had a sharp pain on the right side of my chest. 

The doctor tested me for syphilis using an RPR, chlamdyia, gohonreaa, and HIV using the fourth generation hiv test with reflex. 

I got my results on the 28th of May and was positive for syphilis with a titer of 1:16. My doctor did not suspect that it was syphilis as I did not have any chancres or rash on my feet or hands. I had been checking daily for the last two weeks after the encounter inside my mouth and genitals and saw no sores or ulcers. Is it common to get a chancre inside the mouth from rimming? I found no chancres, which made me fear that maybe the chancre was deep in my throat. The doctor suggested that I return to test again in case the RPR test might be a false positive. He did not treat me for syphilis that day. That same day I decided to test again since the doctor did not seem convinced that I had syphilis. I ordered a syphilis test and an HIV RNA test from stdcheck.com. The results were from Quest Diagnostics. The HIV RNA test came back saying ‘HIV was not detected.’ The RPR (DX) W/REFL TITER AND CONFIRMATORY TESTING for syphilis came back Non reactive. These two exams were done 17 days after my sexual encounter with the other male. I made an appointment with my doctor to let him know about the results for syphilis. By now it had already been 27 days since my sexual encounter. My doctor informed me that he received a call from the public health department and they suggested to him that he give me treatment for syphilis. The doctor gave me a shot of penicillin right before I tested again for all stds, including syphilis and HIV. My doctor used another RPR exam. I got the results back and everything was negative. HIV and syphilis was non reactive. Two weeks later I returned to see my doctor and he informed me that the public health agency requested that i get another syphilis shot. I complied even though the doctor believed I didn’t have syphilis and said the public health department was just being cautious. The doctor also prescribed Sertaline for my anxiety. Over the following weeks my anxiety was getting the best of me despite me taking the Sertraline. 

At 60 days I returned to see my doctor and decided to test again for HIV and syphilis. I had another RPR for syphilis and a fourth generation HIV test. They both came back non reactive. The doctor also informed me that the public health department wanted me to get three more shots one week apart from each other since the public health department believe it could be late syphilis. Prior to engaging in oral sex with another man, I have only been with my girlfriend so I believe that my risky exposure would be from the male I rimmed. 


just to recap on my exams 

-May 11th- received blowjob and rimmed another man. 

-May 24th (13 days after possible exposure) tested for HIV, syphilis, chlamydia, Gonorohra. RPR came back positive with 1:16 titer

-May 28th (17 days post exposure) Tested again for syphilis using an RPR with reflex and confirmatory testing and it was NON REACTIVE. HIV RNA indicated that HIV was not detected. 

-June 7th (27 days post exposure) tested for syphilis again using RPR and came back non reactive. Also tested for HIV with fourth generation test. Came back non reactive. 

-July 10th (60 days post exposure) tested for HIV and syphilis again. Both came back non reactive. By now I had already been given two shots of penicillin. They were given to me two weeks apart from each other. 

  1. Is it possible that the first RPR for syphilis was a false positive? I know my doctor did not do a confirmatory test after, but I did test again three times after the first reactive test with 3 more RPR tests and all three came back non reactive. Also, my doctor gave me a shot of penicillin at 27 days and I tested again the same day for syphilis and HIV after the shot was given to me. The results came back non reactive for both. Since my doctor gave me a shot of penicillin before those exams, could that throw off the RPR? My doctor said that even if I had syphilis it wouldn’t have dropped from 1:16 to non reactive so quickly, which gave him more reason to believe that the first RPR was a false positive. My syphilis test at 60 days was also non reactive. 
  2. Would you recommend that I test again or should I trust that my first exam was a false positive followed by three non reactive RPR exams?
  3. After the fifth week of the possible exposure, I’ve been feeling muscle soreness in my upper back and sometimes my legs and arms. I’m also having pain in my right knee. Im also experiencing neck stiffness at times and loose stools. I’m not sure if this is the anxiety or possibly symptoms of syphilis?? I haven’t had any sores aside from canker sores, but I’m prone to getting them. Especially when I’m stressed out. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Welcome to the forum and thanks for your question. However, it greatly exceeds the word/character limit. It would have been apparent if you had typed it directly into the field provided, but cut and paste (e.g. from Word) bypasses the limit. But the moderators cannot be expected to read such long essays. I've never seen a question on the forum that could not be easily asked in the 1,500 character limit (about 500 words) -- in fact, I'm going to ask you to ask in under 1,00-1,200 characters in the follow-up field below, and then I'll be happy to respond. 

Thanks for your understanding.  HHH, MD
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21 months ago
I am a straight male and had a sexual encounter with another male I met on Grindr. I received a blowjob from him and I rimmed him.  I didn't check his anus for any sores. I contacted him right after as I was scared, and he said he was recently tested for std's and was negative. He also mentioned that he was on prep. 2 weeks after I was experiencing nausea, loose stools, and I had a sharp pain on the right side of my chest.

13 day's post exposure, tested for syphilis, chlamydia, gonorrhea, and HIV using a fourth generation HIV test. Everything was negative except RPR and was reactive with a 1:16 titer. My doctor did not believe it was syphilis due to lack of symptoms such as no chancre sores or rashes. The doctor suggested that I return to test again and was not treated for syphilis.

17 day's post exposure, I ordered a syphilis test from stdcheck.com and the test they used was a RPR W/REFL TITER AND CONFIRMATORY TESTING. It came back non reactive. 

27 day's post exposure, the doctor gave me a shot of penicillin and was tested again for syphilis and HIV. RPR and HIV test came back non reactive. Two weeks later I returned to see my doctor and received another penicillin shot. 

60 days I tested again for HIV and Syphilis. Both RPR and fourth generation test came back non reactive.

1. Is it possible that the first RPR for syphilis was a false positive? I know my doctor did not do a confirmatory test, but I did test again three more times using 3 more RPR tests and all three cam back non reactive. My doctor gave me a shot of penicillin at 27 days post exposure and tested again for syphilis and HIV. The results came back non reactive. Since my doctor gave me a shot of penicillin before those tests, could that throw off the RPR? My doctor said that even if I had syphilis, it wouldn't have dropped from 1:16 to non reactive so quickly, which gave him more reason to believe that the first RPR was a false positive.
2. After the fifth week, I've been feeling muscle soreness in my upper back with neck stiffness at times. Also have soreness in my thighs along with pain in my right leg. I still have loose stools. Could these be symptoms of syphilis??

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
Thanks for the shortened question!

First, this probably was a no-risk exposure. Most people don't lie about STD/HIV status and testing when asked directly, so the chance your partner has syphilis probably is low. And you could have asked your partner to be retested to confirm he is still negative. That would have been a wise move when your own initial RPR returned positive. Indeed, the recommended approach when your initial RPR came back posiive would have been to treat you with penicillin at that time -- while it's best to await the confirmatory test when immediately available, with more than a few days delay, treatment really should have been given; and your sex partner(s), including any recent regular partner(s) in addition to your Grindr guy.

I am amazed that a confirmatory test was not apparently done when your initial RPR was positive, especially with a high titer like 1:16. My bet is that in fact it was done and negative. You and your doctor should contact the lab, and perhaps the local or state public health lab; in many jurisdictions, routine labs automatically refer positive nontreponemal test (RPR, VDRL) specimens to the health department for the confirmatory test. You and your doc should check it out.

Even without a confirmatory test, the subsequent evidence shows that you did not and do not now have syphilis. Your doctor is right that absence of a chancre (the initial syphilitic sore) at the site of exposure made it unlikely you had it. Nevertheless, the routine management described above is generally the way to go, even if it turned out to be unnecessary in your case. When your doctor DID treat you with penicillin, he was being very concervative. Did he actually advise treatment, or did you talk him into it because of your nervousness and uncertainty? While that certainly is understandable and I don't strongly fault your doctor for doing it, if you had been in my STD clinic, we would not have treated you, even if you requested it.

False positive nontreponemal tests (RPR, VDRL, and a few others) rarely come and go:  most people with false positive results have the same outcome whenever tested. More likely it was lab error, or even mix-up of your blood specimen with someone else's. I hope your doctor has been in touch with the lab to make sure they're aware of the situation. From a quality control standpoint, they should know (and should want to know) and might investigate further both to explain your result and assure such an error doesn't happen again. Plus your interest in knowing for sure if a confirmatory test was done and the result. If not already done, your doctor could order a syphilis-specific (confirmatory type) of test now, such as an IgG/IgM ELISA, TPHA, or whatever other such test is offered by the lab your doctor's office uses. 

Is there any way you conceivably could have syphilis? Yes, but extremely unlikely. There is a phenomenon called the prozone effect, in which the initial RPR is falsely negative, but further testing shows the positive result. Most laboratories routinely protect against prozone -- it's quite simple, to test a diluted serum specimen. The chance this was done with the initial positive RPR result but not for later tests is extremely small. But it's still another reason for you and your doctor to be in touch with the lab. In the very unlikely chance a confirmatory test is positive or it otherwise turns out you DO have syphilis, you had it before your Grindr event. It isn't possible to develop a positive RPR, or any other syphilis blood test, only 13 days after exposure. Anyway, a confirmatory test at this time would sort this out and exclude the slim chance you have it.

Those comments pretty well cover your questions, but to be explicit:

1) Your doctor is right. The RPR becomes less strongly positive after penicillin treatment, and usually entirely negative, but this takes several months:  your treatment could not have any effect by the time of your subsequent test results.

2) Your symptoms are not typical for syphilis. More important, you cannot have such generalized symptoms from syphilis with a negative RPR.

So almost certainly all is well. No further syphilis testing is needed, except possibly to consider a confirmatory test now, as discussed above.

I hope these comments are helpful. Let me know if anything isn't clear. You might consider printing out this thread for discussion with your doctor. 

HHH, MD
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21 months ago
Thank you doctor for the quick reply!

I have a couple of more questions regarding my situation.

1. Would you consider my non reactive results for both syphilis and HIV at 60 days conclusive? You mentioned in your reply that no further testing for syphilis is needed, except to possibly consider a confirmatory test. I also wanted to mention that I also tested for HIV using the HIV RNA test at 17 days and HIV was not detected. 

2. Also, I have been with my girlfriend for the past three years. I have not done anything sexual with her in the last two months since the possible exposure occurred. I Have been trying hard to abstain as to not put her in any risk. Would I be safe to continue having unprotected sex with her?

3. Lastly, I know you said the symptoms I described are not attributed to syphilis. I only brought them up because I have been having soreness that comes and goes in my upper back and sometimes my arms along with loose stools and neck stiffness. It could possibly be due to anxiety and stress, which I have been experiencing for the past two months. My doctor prescribed Sertraline and it has been helping, but I just want to be able to put this whole ordeal behind me already. Just to clarify, these symptoms are not related to syphilis, correct?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
21 months ago
1. Yes, conclusive for both HIV and syphilis.

2. You did not need to abstain this long and certainly should resume your normal relations now. 

3. As already discussed, your symptoms cannot possibly be due to syphilis. I haven't changed my mind in the last few hours! For the reasons discussed, I hope you will follow up about confirmatory testing etc, but at this point you can be 100% certain your positive RPR was false and you do not have syphilis and never did. Believe it!
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