RCP-SoPW 2019 – Physicians should be on the alert for patients with untreated syphilis

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by Rachel Pugh

If a physician has not tested any patient for syphilis, they are likely to have missed a case of the sexually transmitted disease (STD), according to Wales top sexual health expert, Dr Olwen Williams.

The Royal College of Physician’s  (RCP) incoming vice president for Wales, made this provocative claim at the joint conference in Cardiff of the RCP/Society of Physicians in Wales, in highlighting what she described as the ‘epidemic’ in syphilis that has developed in the UK in the past five years.

The number of cases of the STD – once thought to be consigned to history - has more than doubled between 2007 and 2017, reaching over 7,798 cases (compared with 3,561 in 2007).

The condition is no longer confined to men-on-men sex, as it was a decade ago. Williams pointed to the ‘scary’ rise in women testing positive for syphilis in antenatal screening clinics. In the past three years, there have been five cases of congenital syphilis in UK.

The re-emergence of syphilis starting in 1997 is, she believes, partly attributable to the introduction then of pre-exposure prophylactic antiretrovirals (PrEP) which made people realise that the risk of dying from HIV had been minimised, and this led to a change towards riskier sexual behaviour.

Williams said: “New cases of syphilis are now double those of HIV, so you really should be thinking syphilis.”

Just under 100,000 people are living with it in the UK but most people receiving treatment have an undetectable viral load, which is a big factor in maintaining the epidemic.

The condition is highly infectious and does not require penetrative sex. Individuals are infectious for two years. Although the condition is treatable with penicillin, 8% of people are unaware they are infected and 40% of these have sequelae which last 20 years.

So, Williams warned that since 1997 marked the start of the epidemic, physicians should now be on the alert for patients presenting to urology and cardiology departments with effects of untreated or partially treated syphilis.

An added complication is that syphilis is one of the great mimics of other diseases:

* Noninfectious conditions: Large B cell lymphoma, sarcoidosis, multiple sclerosis, coeliac disease, Addisons, amyloidosis, fibromyalgia

* Infections: Lyme disease, nocardosis, tuberculosis, brucellosis, malaria, meiliodosis, HIV

“This means that we as physicians need to think outside the box as there is so much of it about,” Williams emphasised.

She emphasised the importance of taking a history including travel and sexualised and recreational drug use. it is also necessary to check the HIV/blood born virus (BBV) risk and testing history.

Interpretation of syphilis serology is difficult as there are many false-positives and it may be necessary to call a patient back for a second sample and repeat all tests.

Diagnosis can be confirmed with syphilis serology and a lumbar puncture, and then treat with Benzyl Penicillin (or for allergies Doxycycline 100mg orally). Neurosyphilis requires procaine penicillin plus probenecid.  A four-fold drop in rapid plasma reagin (RPR) should be anticipated. Partners should be notified, and the patients should be followed up for a year. Untreated 40% will develop tertiary syphilis.