[Question #7679] Syphilis Retest and Anal Issue

1 months ago
I tested positive for Syphilis in November and received treatment (1 shot). I was infected via receiving unprotected anal intercourse. 

My original titer was 1:64. I was retested in late December after treatment and my titer reading was 1:16, leading my dr to believe the shot was effective. I also have no other symptoms. 

I got a full std panel this past week (now almost 3 months post-treatment) but my titer is back up to 1:32. Is this normal? Do I need another treatment? 

The only unprotected sex I had was with the same person as before who was also treated the same time as me. 

Aside from that, I also have been having issues in my rectum. I thought it was hemorrhoids but I also have a strange white/yellow-ish discharge inside my anus. It’s slightly itchy and does hurt when I go to the bathroom. No other symptoms. Also, my std panel came back clean for all other stds. 

Do these things have anything to do with each other? Am I paranoid?  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Welcome back. Thanks for your continuing confidence in our services.

Indeed your RPR titer should have continued to decline. This indicates a high probability of treatment failure -- you need to be in touch ASAP with the doctor treating you. From our previous exchange, it seems s/he is knowledgeable about syphilis, but if any uncertainty -- e.g. if s/he is not an infectious diseases or STD expert -- I would advise seeking out such a provider. Either way, follow your doctor's advice about further diagnostic studies and treatment. Most experts (including I and Dr. Hook) recommend lumbar puncture (spinal tap) in this situation. When syphilis treatment fails, a common reason is that central nervous system infection (i.e. asymptomatic neurosyphilis) was present:  benzathine penicillin alone often fails to cure neurosyphilis -- it gives long but low levels of penicillin in the blood and most organs, but not therapeutic levels in the brain and spinal cord. Not to alarm you, but neurosyphilis is the most dangerous form of the disease, with chance of outcomes like stroke and blindness. So don't delay -- within the coming week for sure (but not an emergency, i.e. no need to be seen today, since it's Sunday).

Your rectal symptoms are more suggestive of gonorrhea or chlamydia more than syphilis. However, syphilis could be responsible, especially if your recent testing include a rectal swab test for gonorrhea and chlamydia with nengative results. Your evaluation now should include anoscopy or proctoscopy -- i.e. internal visual inspection of the rectum. Here too, if you doctor is well experienced in syphilis/STD management, you can expect him or her to have the same recommendation. The evaluation also should include a very careful neurological examination and careful examination of the skin, mouth, etc for subtle signs of continued or recurrent secondary syphilis.

Finally, it may also be necessary to re-contact any and all sex partners you have had in the last few weeks.

I hope these comments are helpful. I look forward to hearing how things go. Good luck with it all.

HHH, MD
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1 months ago
Ok thank you, I will follow up with my dr now. 

For the anal issue, I was tested for both gonorrhea or chlamydia on my std blood/urine test a few weeks ago (no sexual contact since) and they came back negative. Only thing that came up was my titer numbers rising. 

I also did contact the one person who was the other infected person, they have gotten retested and their numbers have declined. Which makes no sense to me. 


H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
Another rectal gonorrhea/chlamydia sense would make sense, especially if your rectal symptoms had not yet started when last tested.

There is nothing unusual about your previously infected partner's declining "numbers" (presumably his RPR test) while yours are not. If your treatment failed, there's no reason to suppose he would experience the same thing. However, if you have been continuing to have sex with him, and if you are confirmed to have failed treatment, then potentially he has been reexposed and will also need repeat prophylactic treatment with benzathine penicillin.

I look forward to the outcome after you've seen your doctor.
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
1 months ago
FYI, I asked Dr. hook to look at this thread.  I should have been clearer that although I am concerned your treatment may have failed, it isn't yet certain.

The blood test standard that defines cure is RPR (or VDRL) declining at least two dilutions (e.g. 1:64 --> 1:16 or lower; or 1:16 --> 1:4 or lower) 6 months after treatment. The decline in titer is not necessarily a steady downward trend. In fact, CDC guidelines don't even recommend retesting until 6 months have passed. My own opinion is that your more frequent testing schedule makes sense and it is pretty much what I have recommended for my own patients. However, RPR titer is not a very precise measure; the same specimen tested several times may give a titers that vary by one dilution. That is, only two-fold changes are considered significant, and your value of 1:16 in December and 1:32 now is not necessarily significant.

That said, in my personal experience, your situation is at least somewhat atypical. With a decline from 1:64 to 1:16 in only a month, 1:32 now is atypical. But in itself it doesn't mean treatment has failed. This is why you need careful examination by an experienced clinician. If careful evaluation finds no other other signs of active syphilis, if anoscopy doesn't suggest syphilis as the cause of your anal discharge, and if no neurological abnormality is found, at this point it's probably too soon for spinal fluid testing. However, that will still be a consideration if your RPR titer hasn't gone back down at that time, and especially if it continues to rise.

I hope all this isn't confusing. You might consider printing this thread as a framework for discussion with your doctor.


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1 months ago
Thank you for the follow up information, Dr. I will relay all of this to my current Dr. tomorrow and hopefully will get some more clarity. Something isn’t adding up so I hope this resolves quickly. 

Thanks