[Question #6384] Syphilis

14 months ago
I was diagnosed and treated for syphilis a little over 6 months ago (I am gay, and HIV negative). I was in the latent stage of the disease when diagnosed and received four penicillin injections for treatment. Today, I had a titer drawn and was told that my new bloodwork was lowered from 32:1 parts to 4:1 parts in my blood. First, does this mean that I have had a successful treatment? Secondly, I am sexually active (but monogamous) so does this reduction in my blood levels allow me to not have to worry about transmitting the disease to my partner? Thirdly, how long should I continue having titers drawn with lowering blood levels, and should I be concerned about the later stages of the disease occurring if my titers continue to lower? Finally, I don't have a primary care doc and no health insurance, so should I make an appointment to ensure that this whole situation is taken care of or is my latest titer a sign that I should be OK?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
14 months ago
Welcome. Thanks for your question and your confidence in our services.

These are all good questions. The doctor or clinic where you were treated undoubtedly can answer them, but I'm happy to do so as well.

1) Your response to treatment is nearly perfect. The titer of VDRL or RPR (the two tests are equivalent) should decline by 3 dilutions within 6 months. 1:32 to 1:4 is exactly that, a 3 dilution decline, so you're right on track. Most likely it will be still lower, and perhaps entirely negative, at your next test about 6 months from now (see no. 3).

2) You were non-infectious for your sex partner(s) within 24 hours of the first dose of penicillin and for sure could not transmit it after that. No worries at all. (I hoope you haven't been holding off on sex all this time! You could have safely resumed sex 6 months ago.) And although you don't mention it, I hope your partner was tested and treated as well, unless your relationship didn't start until after you were treated.

3) Standard advice is for blood tests 1, 3, 6, and 12 months after treatment. You're due for your next test in about 6 months. As long as your RPR/VDRL titer remains stable or declining, for sure you will not develop a later stage of syphilis. Almost certainly you are cured for life.

If cost continues to be an issue for your care, call your local or state health department to arrange your 12 month blood test, or the equivalent institution in countries other than the US. Probably they will be happy te re-test you at no cost.

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

HHH, MD
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14 months ago
Thank you for your response! I am definitely feeling relieved from your answer. I do have a couple of follow-ups just to be 100% clear. First, are there any situations in which my titers would rise aside from being re-exposed? Secondly, if I take an STI in the future how will I confirm my syphilis results? To my knowledge, I will test positive for syphilis for life since my body has the antibodies of the disease, so will I have to retake the VDRL to ensure I haven't been reinfected? I know that there isn't a super high prevalence of the disease, but I managed to catch it once and I would like to not catch it again. Thanks again!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
14 months ago
Going first to your closing comment, I'm afraid you're mistaken. In most of the US, syphilis in men who have sex with men in fact IS "super high". In all of human history, there may have never been higher rates of syphilis than currently occuring in men who have sex with men in much of the US and western Europe. Of course you won't be at risk if you and your partner remain mutually monogamous -- but otherwise, the chance of reinfection may be substantial. 

Your first and second questions are two sides of the same coin:  Penicillin isn't perfect: a few percent fail to respond to the standard treatment, which you apparently had. If your VDRL/RPR titer rises, sometimes it can be difficult to differentiate reinfection from relapse. If in doubt, relapse will be assumed and evaluation and treatment planned accordingly. The details are potentially complex, to be evaluated if it comes up. If and when retested for syphilis in the future, your doc (if knowledgeable about syphilis) will know to request VDRL or RPR. If not certain about the doctor's expertise, you should make that request yourself. All other syphilis tests will be positive, but VDRL/RPR not necessarily; and if positive, the titer dictates next steps.

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