[Question #7433] Syphilis Positive Treatment Question

3 months ago
Hello Doctors,

I made a dumb decision and had unprotected sex with someone about 1.5 months ago. I developed painless red spots on my penis and a rash on my torso. Nothing itched or hurt but I eventually got STD testing and was positive for Syphilis. All other things were negative (HIV etc). 

I had two tests done in one day, both came back positive with RPR Titer reading of 1:32 on 11/3. My Dr. put me on Doxy. I then got retested on 11/18 and my RPR Tier was now 1:64. My Dr. then ordered a single shot of Benzathine Penicillin G 2.4mill Units, single dose. I received that 11/23. 

I am worried about a few things. 

1) I have a longterm relationship that I stepped out on with this encounter. I also had not had any sexual contact with my partner in the last 2 months including right after my other encounter. How likely did I pass anything on, especially with no symptoms?

2) After my shot, I know I am supposed to wait 7 days before doing anything, but will I always be contagious to my partner? If not, when will I know I can have sex again? All of my symptoms have gone away and I never had any open sores or anything like that.

Thank you!
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
Welcome to the forum. Thanks for your question.

I'm glad your syphilis has been diagnosed and you're on proper treatment. I have to wonder why doxycycline was started initially -- benzathine (long acting) penicillin by injection is far and away the first choice and universally recommended treatment except in those who are allergic to penicillin.

Almost certainly you acquired your syphilis earlier than the unprotected event only 1.5 months ago. You clearly have secondary syphilis, and the secondary stage and its symptoms -- like your typical-soundkng skin rash -- rarely begin sooner than 2 months, usually 3 months or more. Six weeks is possible but unlikely, so you need to think back for earlier potential exposures, at least 6 months and possibly up to a year. If there have been no exposures with persons other than your regular partner, then he is the likely source of your syphils. (I don't know you or your partner, and you're obviously in a better position to judge whether he has other partners from time to time. But I'll point out that when one person in a relationship has such needs and behaviors, often the other does so as well.) To your questions:

1) Your regular partner definitely needs testing and probably treatment. If you caught it from a more diatant past exposure, you likely have transmitted syphilis to him. Or as just discussed, he is the source of your infection. The standard procedure in this situation is for your partner to be tested and to be treated with benzathine penicillin immeidately, without waiting for the test result. (If you are in the US or other industrialized country, your infection probably has been reported to your local or state/provincial health department, and they probably will be in touch with you soon and you can expect them to give this same advice -- and to contact your partner themselves if you wich them to do to.)

2) You are no longer infectious; transmissibility of syphilis ends within 24 hr of starting effective treatment. However, you need to hold off on sex with your partner to avoid reexposure, until you know for sure he doesn't have it or he has been treated.

Final advice:  You don't mention HIV. Among men who have sex with men, half or more of people with syphilis also have HIV. If not infected (or known to be infected), you need HIV testing now.

 I'll be interested to know the outcome after your partner has been informed, tested, and (I hope) treated. In the meantime, I hope these comments are helpful.

HHH, MD
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3 months ago
Thank you for the response, Dr. Handsfield,

To answer your questions:

1) There is a chance it is older, but I have never had symptoms that I have noticed until this first time. I also have a few others I have been with who have since been tested and came up negative for Syphilis. My Dr. said there is a chance it is Late/Tertiary? Is there any way of telling how long I have had it?

I have never had marks on my penis before and my long-term partner is a woman. As of now, she has no symptoms of anything and never has had any. She also saw her normal Gynecologist about 1.5 months ago who would have mentioned seeing anything inside I assume like red marks. 

If I indeed have had it for longer than 3-6 months, was one shot of Penicillin enough? 

I was tested for HIV as well along with the most recent STD testing and it all came back negative/non-reactive thankfully. 

I did notice in my Hepatitis Panel that my Hep C Index Value said "0.19" Result. Does this mean anything?

Thank you again


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
Your rash denotes secondary syphilis. That usually means infection between 3 and 6 months in duration, sometimes as long as a year; and, very rarely, up to 4 years. Beyond a year is so rare it can be ignored. Also, your RPR titers of 1:32 and 1:64 are quite high and typical for secondary syphilis. Even without treatment, the titer usuallly declines after the first year, so those numbers are most compatible with the 3-6 month (maybe 12 month) time frame. So you can safetly assume you've been infected for no more than a year and probably for 3-6 months.

The primary syphilis lesion -- called a chancre -- usually is painless and is easily missed, especially if it occurs in a hidden location (e.g. rectum, vagina, etc). Therefore many people with secondary syphilis -- which you obviously have -- experience no symptoms of primary infection. Usuallly this is because the intitial lesion (the chancre) is hidden, e.g. in the rectum or vagina. In some cases, it's sufficiently mild that even external lesions are not noticed. 

That your regular partner is female statistically makes syphilis less likely than in men having sex with men. Still, in this circumstance, she probably is infected -- even if not the source of your infection, she has been exposed when you were highly infectious. There's nogetting around the absolute requirement that she be tested and treated.

I'm glad to hear your negative HIV result. But in the presence of newly diagnosed syphilis, it probably would be wise to be tested again -- although that depends on the tming. If >6 weeks after your last exposure to a male partner, repeat testing isn't necessary.

Your hepatitis C test result is negative.
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
3 months ago
Clarifications:

1) Regardless of their negative tests, your "few other" (male?) partners should all be retested. There is a 4-6 week window when people with newly infectious syphilis often are infective, i.e. can transmit, but who have negative blood tests. It would not be surprising if one of them is the source of your infection and now would test positive. (The difficulty and uncertainty of successfully reaching multiple partners is one of the main reasons that health departments should become involved in partner notification. They'll probably be happy to help if you cannot reliably contact some of them.)

2) Duration of treatment (I forgot to answer above):  If no source can be identified, it would increase the likelihood your infection is more than a year in duration. As I said above, that's rare -- but not unheard of. If longer than a year, the benzathine penicillin should be repeated twice at weekly intervals, i.e. a total of 3 doses, 7-10 days apart. Also, in that circumstance you need a very careful neurological examination; and even if that is normal, some experts would also recommend a lumbar puncture (spinal tap) to check for evidence of neurosyphilis, i.e. brain and spinal cord involvement. NS is unlikely without neurological symptoms, but not unheard of -- and highly dangerous if not detected and treated with high dose IV penicillin.

I'm hoping to hear the outcome after your regular partner has been tested. Hope it happens soon and you'll keep us posted!
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2 months ago
I just wanted to update you. 

My partners test came back negative, so that’s good. I received my shot on 11/23 and have not had any sexual contact with anyone or symptoms since then. 

When should I be retested and am I safe to have sex again with my normal partner without risk of infection?

Thank you
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
2 months ago
Thanks for the follow-up. Glad to hear your partner's test was negative, but he needs to be treated. All contacts of persons with infedtious syphilis -- and secondary is the most infecious stage -- should be treated with benzathine penicillin. He also needs a second blood test in a few weeks.

You were non-infectious yourself within 24 hours of getting the penicillin shot. You and he can safely resume sex together after he has been treated, but not before then. (If he is incubating the infection, it could be passed back to you.)

Your retesting schedule should be in the hands of the doctor or clinic treating you. CDC recommends retesting 6 and 12 months after treatment, but many experts recommend more frequent testing. My own usual advice is 1, 3, 6 and 12 months; and sometimes 9 months, depending on the 3 and 6 month results.
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2 months ago
Ok thank you for the information, Dr. 

 My fear is putting my female partner through the treatment, even though she tested negative and we have not had sexual contact since late October. I will suggest it to her either way though. As I had no symptoms etc on my penis during this whole thing, I believe my sore was inside my anus (which I obviously didn’t see), my female partner would have never came in contact with that. I’m being as safe as possible with this, but she is weary of getting an injection if not needed.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
2 months ago
I see no need for your regular partner to be informed or tested. However, if it would reassure you and are comfortable discussing the situation with her, you should do so; she might be very supportive. Then let her make the decision whether or not to be tested. For sure she should not be treated until or unless she is tested with a positive result.

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