Primary and Secondary Syphilis

• After 6, 12, and 24 months of treatment, reexamine the patient and recommend a follow-up quantitative nontreponemal titer. If the patient is asymptomatic, yet has a fourfold increase in nontreponemal titer or persistent or recurrent symptoms are observed, order an HIV test and a lumbar puncture; if the patient is HIV-positive, suggest an infectious disease consult.

Primary or secondary syphilis diagnosed and treated with benzathine penicillin G, 2.4 million units IM (single dose)'

Follow-up al 6 months: repeat clinical examination and quantitative non-treponemal test titers

Persistent or recurrent clinical signs or symptoms

No signs or symptoms, but persistent fourfold increase in non-terponemal titers

No signs or symptoms, and fourfold decrease in non-treponemal test titers

HIV testing and lunbar punctur©

EBB

Follow up in 6 month3: repeat clinical examination

Infectious disease consultation

Lumbar puncture negative

Lumbar puncture findings compatible with neurosyphilis

Benzathine pencillin G, 2.4 million units IM orce weekly for 3 weeks (3 doses)*

Treat for neurosyphilis as per recommendations5

Follow-up in 6 months: repeat clinical examination and nontreponemal test titers

FIGURE 80-2. Patient care monitoring for syphilis. (From Brown D, Frank J. Diagnosis and Management of Syphilis. Am Fam Physician. 2003;68(2):283-290.) (a See text for alternative treatment recommendations for nonpregnant penicillin-allergic patients. See text for treatment recommendations for neurosyphilis.)

• In patients who are both negative for HIV and the lumbar puncture, administer benzathine penicillin G 2.4 million units intramuscularly once weekly for three additional weeks. Perform a patient follow-up in 6 months including a clinical examination and another nontreponemal titer. In HIV-negative patients with lumbar puncture findings compatible with neurosyphilis, treat the patient accordingly for neurosyphilis.

• Six months after the original diagnosis, institute a standard clinical follow-up exam in patients who show no symptomatology and a fourfold decrease in nontreponemal titers. By testing and observing the patient for signs of remission, you may be able to initiate proper treatment or recommend a consult in a timely fashion, thereby decreasing the propensity of the patient's condition to advance to a higher stage.

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