[Question #6483] Syphilis, again

13 months ago

Hi, after my treated syphilis infection with penicilin in 2015, I visit my STD specialist once a year to get my treponemal and non-treponemal syphilis titres checked (Mid-October 2019: RPR non-reactive, TPPA 1:5120).

End of November I felt intense pain in my rectum. It was a day after having sex with a 'big' guy (with a condom). On the 2nd day I noticed an anal ulcer, for which I hoped it was just an anal fissure in anterior midline, but in a day or two a pronounced chancer formed. So I just started taking doxycycline (100 mg 2x day, 14 days) and the chanker completely resolved after 2 weeks.

27 days after I first noticed my anal ulcer, I had my blood checked again: RPR non reactive and TPPA 1:10240 (tppa is higher!).

I am aware that the onset of my symptoms can be result from any sexual contact that I might have had within the last 3 months.

Also, within the last month I experienced mouth canker sores (coming and going) and groin and abdominal pain although lymph nodes seem normal. For the last 10 days I also experienced something like a painful hemorroid, but it got better today (I noticed some blood on the paper, so I assumed it might have burst, BUT, when I look at it in the mirror, the wound looks similar as previously described ulcer and it is on the same spot as previously mentioned chankre.)

Q1: How frequent should I get my blood tested from now on (monthly, every two months..) not to miss possible RPR increase? If my RPR will ever becomes positive, I will run to a doctor for a penicilin shot.

Q2: If my TPPA keeps getting higher (20480, 40960...) and RPR remains non-reactive, what would that mean? Is that possible? Would I in this case have to seek penicilin treament?

Q3: How concerned should I be with my anal open sore that I noticed today on the site of the 'previous chancre'. I hope it is related to a hemorroid, but if it is syphilitic, can I expect rise in RPR in a few weeks?

I am looking forward to hearing your professional opinion. Kind regards
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Welcome to the forum. Thanks for an interesting question.

Chancres usually are not painful, nor can a syphilitic ulcer (chancre) appear in only a day or two. And with recurrence of another ulcer in pretty much the same spot, herpes is the best bet, not syphilis. Healing over 1-2 weeks is typical for initial herpes, so its improvement didn't necessarily have anything to do with the doxycycline.

It was a mistake to treat yourself in this manner (assuming it indeed was self-treatment, and not prescribed by a doctor or clinic). The main result is that it makes it impossible to ever know whether in fact the new problem was syphilis. (Although 1-2 days is too soon, if you had been exposed to someone with active syphilis in the previous 2-3 weeks, maybe it had nothing to do with the most recent encounter.) The good part, however, is that 2 weeks of doxycycline is 100% effective in aborting incubating syphilis or curing early infection. Even if the initial lesion was a chancre, you'll never develop a positive blood test as a result. You can continue to follow your doctor's advised schedule on periodic retesting for syphilis. In the event of a newly positive RPR or other evidence of reactivated syphilis, it will date back to your original infection and not the more recent anal ulcers.

Those comments pretty well address your specific questions, directly or indirectly. But to be explicit and assure no misunderstanding:

Q1. Once a year is fine. As noted above, your recent events can have no effect on your syphilis blood tests. It probably wasn't syphilis, but it wouldn't matter if it was.

2. Repeat TPPA isn't usually recommended or necessary. I would advise only repeat RPR once a year. However, since you've apparently been in the care of an STD expert, who may have somewhat different perspectives on this, you should follow his or her advice.

Q3. I recommend promt exmination and testing of the ulcer for HSV by PCR. Do it ASAP:  in recurrent herpes, PCR for HSV may remain positive for only a few days. If PCR is negative and your STD specialist agrees herpes is possible, blood tests may sort it out.Herpes is far and away the most common cause of recurrent genital or anal ulcers. That said, a recurent anal fissure -- related perhaps to trauma during the anal sex episode and not due to any infection -- also is possible. Again, direct exam by an experienced provider is the only way to sort this out.

Probably it doesn't need to be said, but no sex involving your anal area (and preferably none at all) until this is all sorted out.

I hope these comments are helpful. Let me know if anything isn't the clear.

13 months ago
Thank you so much for your promt reply and advice. I had four encounters in the previous 4 months, and I do not suspect the last one as cause of my problems, since 1 or 2 days is too soon for the onset of my symptoms (especially syphilis). 

I checked again the new ulcer: it is actually at the exact opposite side (in the posterior (back) midline), not where the first one was. My mistake before, I am sorry.  I have never experienced any bumps, blisters or itching, therefore my thoughs were not going into direction of HSV. Both ulcers have been well defined, with clear edges. And why do for the second one suspect a hemorrhoid burst? Up until two days ago I felt pain like from an inflammed hemorrhoid,  which actually started after straining while having a bowel movement about a week (or 10 days) ago. The annoying pain went away not before yesterday afternoon, after a whole day of skiing. Today I noticed a trace of light blood on the paper, and having a looked at this ulcer just now, I see that it has a clear edge and a dark, blackish base. But it is not painful.

Q1: Could mild abdominal pain above my pubic bone and mild groin pain be anyhow related to my explained symptoms (that is, is it std related)? I had no penile discharge, itching whatsoever.  

Q2: You wrote that my recent events could have no effect on blood test results. Nevertheless, I will continue to pay attention on my RPR and will check it every 3 months for a year, to make sure it stays non reactive. 
But what about treponemal test TPPA? I know that it does not correspond with treatment success/failure, but it still raised my concern, because it has risen for one dilution in a month or two. (but I do not know whether they tested my blood in the same laboratory or not).

Many thanks for your answers, I sincerely appreciate it.

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
Thanks for clarifying things. This makes anal herpes less likely, but doesn't rule it out. Many cases of herpes lack typical blisters; ulcer alone is quite common. If I were you -- or if you were my patient -- I would be tested for herpes. Maybe it won't pan out, but bettere safe than sorry.

Q1. Abdominal pain is unlikely to be related in any way to the anal ulcers, syphilis, or any other issues you have raised.

Q2. To my knowledge, TPHA titers have never been studied and I cannot say how they might vary over time. In general, one dilution difference in any titered test usually is insigificant. However, as long as RPR remains negative, you can be confident syphilis has not relapsed. I see no need or reason for testing more often than once a year, unless and until you have other new symptoms (not counting your recent anal ulcers) that suggest a new infection.

Thanks for the thanks. I hope these additional comments also are helpful.
13 months ago

Thank you, Mr. Hunter, for the amazing assistance. For my last thoughts, I would like to quote this definition: 'Treatment failure is defined as persistent symptoms or signs, OR a sustained four-fold increase in non-treponemal test titer'. 

1.  You are saying that my persistent abdominal pain tenderness and a weird feeling in groin and pubic area are not to be attributed to syphilis (or its treatment failure), and I should therefore have no reason to worry, especially if my RPR remains nonreactive for the next month or two, right? (i will get another rpr test done, to be reassured)

2. In case that my RPR stays nonreactive, but TPPA titer increases once more, would that indicate a need for additional action?

Many many thanks for all your help and effort. I am very grateful for your service. Kind regards, R.  

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
13 months ago
That definition is correct. "Non-treponemal" means RPR or VDRL. TPPA is a treponemal test. As long as your RPR remains negative, your syphilis is cured and not likely to relaps, and you have not been reinfected.

1) Correct. Abdominal pain and "weird feelings" in the groin are not symptoms that suggest syphilis.

2) Once again, to my knowledge there has been no research on utility of tittered TPPA (or any other confirmatory test) in following patients treated for syphilis. TPPA and TPHA titering have been investigated as aids in diagnosing congenital syphilis and in predicting neurosyphilis in patients with untreated syphilis, but I am unaware of data on whether such titers can be expected to vary after syphilis treatment, especially when the RPR remains negative. And a quick investigation of the worldwide medical literature databases reveals ntohing that I can find. I would stop having TPPA titers at all and follow only your RPR, and see no reason to do it more often than once a year.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the disucssion has been helpful. Best wishes and stay safe.