Syphilis Roadshow 03.17.18 PC VERSION · symptom recognition secondary tertiary early latent late latent joe engelman, sf city clinic. 21 symptom recognition primary secondary tertiary

1

Lisa Villarroel, MD MPHMedical Director, Division of Public Health Preparedness

Arizona Department of Health Services

Disclosures:

None

2

Fitzgerald TJ, Cleveland P, Johnson RC et al: Scanning electron microscopy of Treponema pallidum (Nichols strain) attached to cultured mammalian cells. J Bacteriol 130:1333, 1977.

PRIMARY

CDC Library

PRIMARY

3

CDC PHIL 16750

PRIMARY

CDC PHIL 12578

PRIMARY SECONDARY

4

CDC Library

PRIMARY SECONDARY

CDC Picture Cards

PRIMARY SECONDARY

5

CDC Library

PRIMARY SECONDARY

PRIMARY SECONDARY EARLYLATENT

6

PRIMARY SECONDARY EARLYLATENTLATE

LATENT

PRIMARY SECONDARY EARLYLATENTLATE

LATENT

7

PRIMARY SECONDARY TERTIARYEARLYLATENTLATE

LATENT

CDC clinical slides


LATENT

8

NEUROSYPHILIS CAN OCCUR AT


LATENT


LATENT

TRANSMISSION TO THE FETUS CAN OCCUR AT ….


9

CDC clinical slides


CDC PHIL 16750


10





LATENT

11


LATENT


LATENT

12

Credit: National Archives.


LATENT


LATENT

13


LATENT




LATENT

14

RAT

E

15

MEN WHO HAVE SEX WITH MEN

MEN WHO HAVE SEX WITH WOMEN

PRIMARY & SECONDARY SYPHILIS CASES

MEN WHO HAVE SEX WITH MEN

WOMEN

MEN WHO HAVE SEX WITH WOMEN

PRIMARY & SECONDARY SYPHILIS CASES

16

ARIZONA

U.S.

2007 2010 2013 2016

PRIMARY & SECONDARY SYPHILIS RATE / 100,000

2012 2013 2014 2015 2016

PRIMARY & SECONDARY SYPHILIS CASES IN ARIZONA

17

2012 2013 2014 2015 2016

BLACK (24)

AMERICAN INDIAN

HISPANIC

WHITE

ASIAN (4.5)

PRIMARY & SECONDARY SYPHILIS RATE / 100,000

0

10

20

2012 2013 2014 2015 20160

15

30 ARIZONACASE RATE

U.S. CASE RATE

CONGENITAL SYPHILIS CASES & RATES / 100,00

18


LATENT

19

SYMPTOM RECOGNITION


LATENT

PRIMARY

SYMPTOM RECOGNITION

SECONDARY TERTIARYEARLYLATENTLATE

LATENT

20

PRIMARY

SYMPTOM RECOGNITION


LATENT

CDC Syphilis Images

PRIMARY

SYMPTOM RECOGNITION


LATENT

Joe Engelman, SF City Clinic

21

SYMPTOM RECOGNITION


LATENT

SYMPTOM RECOGNITION


LATENT

CDC Syphilis Images

22

SYMPTOM RECOGNITION


LATENT

CDC Syphilis Images



LATENT

Review of Ophthal,, 2008

23



LATENT

Review of Ophthal,, 2008

SCREEN


LATENT

24


LATENT


LATENT

25


LATENT

LABORATORY TESTING


LATENT

26

NONTREPONEMAL TESTS

RPR, VDRL

TREPONEMAL TESTS

TPPA, FTA-ABS

CIA, EIA (NEW)


LATENT

YEARSWEEKS

TIME POST-INFECTIONTIME OF

INFECTION

27

TREPONEMAL TESTS(TPPA, FTA-ABS)

WEEKS


INFECTION

YEARS

NONTREPONEMAL TESTS(RPR, VDRL)

TREPONEMAL TESTS(TPPA, FTA-ABS)

WEEKS


INFECTION

YEARS

UNTREATED

TREATED

28


LATENT

NONTREPONEMAL TESTS

RPR, VDRL

FOLLOWS RESPONSE TO TREATMENT

1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024

29

1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024

2-FOLD CHANGE

1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024

2-FOLD CHANGE

4-FOLD CHANGE [SIGNIFICANT]

30

NONTREPONEMAL TESTS

RPR, VDRL


CAN VARY DAILY


LATENT

NONTREPONEMAL TESTS

RPR, VDRL


CAN VARY DAILY

ARE FALSE POSITIVES


LATENT

31

NONTREPONEMAL TESTS

RPR, VDRL


CAN VARY DAILY

ARE FALSE POSITIVES

ARE RARE FALSE NEGATIVES


LATENT

TREPONEMAL TESTS

TPPA, FTA-ABS, CIA/EIA

.


LATENT

32

TREPONEMAL TESTS


.GOOD, EARLY PERFORMANCE

REACTIVITY PERSISTS OVER TIME


LATENT

TREPONEMAL TESTS


.GOOD, EARLY PERFORMANCE

REACTIVITY PERSISTS OVER TIME

LESS FALSE POSITIVES (FTA, EIA MAIN PROBLEM)


LATENT

33

NONTREPONEMAL TESTS

RPR, VDRL

TREPONEMAL TESTS


.


LATENT

NONTREPONEMAL TESTS

RPR, VDRL

TREPONEMAL TESTS


.


LATENT

34

Am J OB and GYN, April 2017

TRADITIONAL

NONTREPONEMAL (RPR)


TRADITIONAL

NONTREPONEMAL (RPR)

35


TRADITIONAL

NONTREPONEMAL (RPR)

TREPONEMAL


TRADITIONAL

NONTREPONEMAL (RPR)

TREPONEMAL

36


TRADITIONAL

NONTREPONEMAL (RPR)

TREPONEMAL

TREPONEMAL (EIA/CIA)

REVERSE


TRADITIONAL

NONTREPONEMAL (RPR)

TREPONEMAL


REVERSE

37


TRADITIONAL

NONTREPONEMAL (RPR)

TREPONEMAL


NONTREPONEMAL (RPR)

REVERSE


TRADITIONAL REVERSE

NONTREPONEMAL (RPR)

TREPONEMAL


NONTREPONEMAL (RPR)

TREPONEMAL (TPPA)

38


TRADITIONAL REVERSE

NONTREPONEMAL (RPR)

TREPONEMAL


NONTREPONEMAL (RPR)

TREPONEMAL (TPPA)


TRADITIONAL REVERSE

NONTREPONEMAL (RPR)

TREPONEMAL


NONTREPONEMAL (RPR)

TREPONEMAL (TPPA)

39


TRADITIONAL REVERSE

NONTREPONEMAL (RPR)

TREPONEMAL


NONTREPONEMAL (RPR)

TREPONEMAL (TPPA)


LATENT

STAGING

40

SYMPTOMS = PRIMARY / SECONDARY STAGES


LATENT

NO SYMPTOMS = LATENT STAGES


LATENT

41

NO SYMPTOMS = LATENT STAGES

EARLY IF IN PAST YEAR

NEG SYPHILIS SEROLOGY

KNOWN CONTACT TO EARLY CASE OF SYPHILIS

HISTORY OF SYMPTOMS

SUSTAINED 4x INCREASE

ONLY POSSIBLE EXPOSURE

LATE IF IN PAST YEAR

(NONE OF THOSE)


LATENT


LATENT

42

SYMPTOM RECOGNITION


LATENT

43

SYMPTOM RECOGNITION

EMPIRICALLY TREAT


LATENT

SYMPTOM RECOGNITION

PARTNERS WITHIN 90 DAYS

EMPIRICALLYTREAT

EMPIRICALLY TREAT


LATENT

44


LATENT


LATENT

GET HISTORYTREATMENT NEEDED?

45

SYMPTOM RECOGNITION

PARTNERS WITHIN 90 DAYS

EMPIRICALLYTREAT

EMPIRICALLY TREAT

PRIMARY SECONDARY

GET HISTORY

TERTIARYEARLYLATENTLATE

LATENT

TREATMENT NEEDED?

BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM

x 1, ONCE


LATENT

46


x 1, ONCE


x 3, Q WEEK


LATENT

DAY OF TREATMENT CHECKLIST


LATENT

47

GET A TITER (REALLY).



LATENT



DAY OF INITIAL LAB TEST DAY OF TREATMENT DAY OF FOLLOW UP

RPR 1:256 RPR 1:256RPR 1:1024

[NOT CHECKED]


LATENT

48


WARN ABOUT JARISCH-HERXHEIMER.



LATENT



COUNSEL NO SEX x 1 WEEK.



LATENT

49




ADVISE THAT ALL PARTNERS BE EVALUATED.



LATENT





CONFIRM HAS BEEN TESTED FOR HIV.



LATENT

50





CONFIRM HAS BEEN TESTED FOR HIV.

ESTABLISH FOLLOW-UP EXPECTATIONS.



LATENT


LATENT

FOLLOW UP

51

FOLLOW UP

SEROLOGIC TESTS ~Q6 MONTHS.


LATENT

HIV (-) HIV (+)

PRIMARY / SECONDARY SYPHILIS

6, 12 MONTHS

3, 6, 9, 12, 24 MONTHS

EARLY LATENT / LATE LATENT SYPHILIS

6, 12, 24MONTHS

6, 12, 18, 24MONTHS


LATENT

FOLLOW UP


TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO.

52



SUSPECTED TREATMENT FAILURE OR REINFECTION IF:

4-FOLD INCREASE IN TITERS

OR NEWLY SYMPTOMATIC

OR TITERS DON’T DECLINE


LATENT

FOLLOW UP



SUSPECTED TREATMENT FAILURE OR REINFECTION IF:

4-FOLD INCREASE IN TITERS

OR NEWLY SYMPTOMATIC

OR TITERS DON’T DECLINE


LATENT

FOLLOW UP

NEW HIV TEST? LP for CSF VDRL

? RETREAT (BICILLIN x3)

53


LATENT

54

DATA

DATA PARTNERS

55

DATA PARTNERS POLICY

DATA PARTNERS POLICY ANSWERS

56



CALL PUBLIC HEALTH

57

.


LATENT

.


LATENT

58

[email protected]

Joseph EngelmanKristen Herrick

Susan RobinsonStephanie Cohen

Laura DaltonPaul Bloomquist

CAPTCRoxanne Ereth

Rebecca ScrantonTymeckia KendallDon Herrington

ACKNOWLEDGEMENTS

59

EXTRA SLIDES

60

Rac Syphilis in Pregnancy OB GYN

62

STAGE STARTS LASTS (untreated) Other sxs Infectivity

Primary 10d‐12 weeks after inoculation (median time 21 d)

1‐6 weeks • Papule‐>Chancre• Nontender regional adenopathy

• Infectious by direct contact or blood

Secondary • 2‐8 weeks after chancre heals or

• 4‐8 weeks after onset of chancre

• can overlap with 1ary

“Several weeks” • symmetric, bilateral rash• mucous patches/condyloma lata• fever, headache, pharyngitis• hepatitis, osteitis,

glomerulonephritis• meningitis/ocular/oto‐

• Infectious by direct contact (when mucosal lesions present) or blood

Early Latent After resolution of 2ary symptoms

• Until 1 year after inoculation

• can alternate with2ary

• Neurologic: meningitis, ocular, oto‐, meningovascular (strokes)

• Infectious by direct contact (when mucosal lesions present) or blood

Late Latent 1 year after inoculation Until treatment or development of late symptomatic disease

• Infectious by blood

Late Symptomatic

15‐25 years after inoculation

Until treatment • General paresis (CNS parenchyma)

• Tabes dorsalis (posterior columns: sensory/proprio)

• Cardiac (aortitis, infarction)• Late benign (gummatous)

Ghanem. CNS Neuroscience & Therapeutics 2010;6(5): e157-68

63

“Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you.” – William Osler, 1909

“Syphilis… remains the despair of the statistician.” -- William Osler, 1917

“When it comes to syphilis, suspect your grandmother” – William Osler

“The souls of infants born only to die or suffer, cry out against the infamy of uncured syphilis.” – (well known venereal syphilologist)

“With our present appropriations, Federal and State and private, we might just as well try to empty the Pacific Ocean with a teaspoon.” – Dr. OC Wenger, 1926

Documents

Syphilis Roadshow 03.17.18 PC VERSION · symptom recognition secondary tertiary early latent late latent joe engelman, sf city clinic. 21 symptom recognition primary secondary tertiary