[Question #7656] could it be syphilis?

1 months ago

Hello Dr.

One and a half years ago I notice a red little pimple on the root of my penis, just in the place usually uncovered by a condom, in some few days it open and it looked like a little sore. As I had had an encounter sometime before with a masseuse (I don´t remember how many days before), I took a Test for Syphilis that was negative (FTA-AB) eight days after I noticed the pimple. As I am a sanitary worker and was very worried, I got an injection of penicillin G-benzathine 2.400.000 IU. The little sore healed in two or three days. That was in September 2019.

In July 2020, I had a low fever that lasts just one day, it repeats 3 weeks after and I did a blood test that showed 14.000 Leucocytes with neutrophilia. Same days after leucocytes got normal. This episode has been repeating 4 times more from them until now: fever that lasts one day with Leucocitosis and neutrophilia. The last episode was last week. I have not other symptoms.

Could it be syphilis from the encounter I described above? Do I need to test again for syphilis?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Welcome back, but sorry you found it necessary.

First, the initial sore of syphilis (the chancre) doesn't usually start as a pimple. Second, chancres 10-20 days after exposure; although you are uncertain about the timing, "a few days" (under 10 days") is incompatible with syphilis. Third, you had the wrong syphilis blood test and it was to soon:  initial testing should never be FTA-ABS; and no syphilis blood test can be positive only 8 days after onset of a chancre. Finally, if you had indeed acquired syphilis -- and if the penile sore was a syphilitic chancre -- treating with penicillin so soon after onset is 100% certain to cure an early case or abort infection before it ever takes hold. In that situaiton, the blood test never becomes positive.

Therefore, your July 2020 fever and transient leukocytosis could not have been syphilis, unless you were reexposed since the event with the massuse. Even then, syphilis rarely if ever presents with fever and leukocytosis. That event was some other infection, definitely not syphilis nor any other infection from the sexual encounter several months earlier.

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

HHH, MD
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1 months ago
Hello Dr. Handsfield. I see that the goal is that my fever episodes are not related to syphilis, and that is the important thing.

But you said that "not syphilis blood test can´t be positive 8 days after onset of a chancre" and I am a little confused because Dr. Hook says otherwise in an answer to another person,  question #7599: 
Question: "3. If this was syphilis sores if I test for it now or sometime this week would it show as a positive for syphilis ?"
Answered Dr. Hook: "3.  If this were Syphilis since the lesions have been present for several days, a Syphilis blood test would be positive."  "Once lesions appear, blood tests become positive within 2-3 days of appearance.  Thus a negative blood test at this time would be strong evidence that your lesions are not due to Syphilis".

The reason for doing  FTA-AB,  In the lab, told me that they are using the reverse protocol, a first treponemal test that is more sensitive but has 2% of a false positive, and if it is positive, they do a nontreponemal one.

Thank you for your patience and congratulations for your work here.

Resultados de traducción

They are using the inverse protocol, first treponemal tests that are more sensitive and in case of positive they do non-treponemal tests
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Yes, potentilly confusing replies. In studies done many years ago, and longstanding clinical experience, roughly half of people with chancre have positive (nontreponemal) blood tests, depending largely on how soon they are tested after chancre onset. Most with chancre only a day or two have negative blood tests; after a couple of weeks, almost all have positive results. The exact time course during those weeks has never been carefully studied; some may be positive 2-3 days later, but others probably take longer.

The other factor is that, as noted in my reply above, chancre onset is almost always 10-20 days after exposure. That in turn is consistent with a time frame like this:  exposure day zero, chancre onset day ~14, blood test becoming positive maybe day 21-30. And a few take still longer, justifying common advice that testing detects 90-95% of infection by 4 weeks and virtually all by 6 weeks.

Your understanding of your blood test results is confusing. The reverse algorithm starts with an IgG test. If positive, a nontreponemal test is done, such as RPR or VDRL  -- not FTA-ABS, which is another treponemal test. If you had a positive IgG, you should also have had both an RPR or VDRL as well as a second treponemal test. The usual second treponemal test these days is TPPA and a couple others, usually not FTA-ABS. However FTA counts, and perhaps your lab does this in preference to TPPA or others. That negative result suggests you did not have syphilis, but was done too soon to be certain

But all this is really not relevant to your more recent episode of fever and leukocytosis. Even if you had early syphilis, without yet having a confirmed positive blood test, treatment with penicillin at day 11 is 100% curative and prevents the blood test ever becoming positive. As we also discussed, fever and leukocytosis for one day would be very atypical manifestations of syphilis. If you would feel better, you could have another syphilis blood test at this time. I'm confident it would be negative. Whether or not you had incipient syphilis in the days following the sexual exposure, you do not have it now and never will have a positive blood test or any possibility of syphilis reactivating.

I hope that helps clear things up.
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1 months ago
Hello Dr. 
I just have seen the results of the treponema Antibodies  Screening test that they did yesterday, and is negative. 
Now  it only remains to investigate with my doctor the cause of my recurrent fever.....
Than you very much for your help and congratulations for  the forum. 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
I apologize about one aspect:  I forgot that your brief periods of fever and leukocytosis have recurred; I was thinking a single episode. It makes no difference in my assessment in regard to syphilis, and of course I am not surprised by your newly negative syphilis test. But certainly this requires further evaluation. (Are you by any chance at risk for malaria, e.g. travel to a malaria endemic area?) Depending on the expertise of your personal physician, consider consulting with an infectious diseases specialist.

That concludes this thread. Thanks for your kind words about the forum. Best wishes and stay safe.
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