Didactic Series. STD Screening & Management: Syphilis. Christian B. Ramers, MD, MPH

Transcription

1 Didactic Series STD Screening & Management: Syphilis Christian B. Ramers, MD, MPH Assistant Medical Director Family Health Centers of San Diego Ciaccio Memorial Clinic 3/26/15 ACCREDITATION STATEMENT: University of California, San Diego School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The University of California, San Diego School of Medicine designates this educational activity for a maximum of one credit per hour AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity. Disclosure Statement: Speaker has no personal financial relationship with a commercial interest that produces, markets or distributes health care goods or services 1 discussed in this presentation.

2 Learning Objectives 1) Describe the surging epidemiology of Syphilis in MSM and HIV+ populations 2) List recent changes in Syphilis testing 3) Review clinical stages and corresponding treatment of syphilis 4) Discuss disturbing cluster of ocular syphilis cases in Western US 2

3 Centers for Disease Control (CDC) December 17, 2010 STD Guidelines

4 aidsinfo.nih.gov DHHS: CDC, NIH, HIVMA, IDSA October 28, 2014 Adult OI Guidelines

5 Which of the following is TRUE regarding Syphilis in the United States? 1. Syphilis rates are the highest they have ever been in recorded history 2. Antibiotic resistance is becoming a problem for treatment algorithms 3. Recent resurgence has led to the highest rates in 20 years 4. Incidence is stable, but prevalence is rising

6 Syphilis Epidemiology - CA Syphilis (all stages) CA incidence rates CA STD Surveillance report 2013

7 Syphilis Epidemiology - CA Primary & Secondary Syphilis Cases by Gender California ( ) Source: CA Dept. of Public Health STD Control Branch

8

9

10

11

12

13

14

15 Case #1 - JT HPI: 24 yo male presents with 1-2 weeks malaise, headache, fevers, rash, decreased visual acuity PMedHx: HIV dx d 2012, stable on FTC/TDF/RPV, recent CD4 = 410 cells/ml, VL < 40 copies/ml SocHx: - Social EtOH and occasional Tobacco - Has experimented with methamphetamine - MSM, 7 lifetime partners, new partner x 3 months PEX: T 38.2, 94, 128/78, 97%, 165 lbs

16 Case #1: Rash

17 Which of the following is the best approach? 1. Serum RPR today, follow-up in 3 months 2. Syphilis IgG today, follow-up in 3 months million units Benzathine PCN NOW, no lab testing necessary 4. Serum RPR today, Benzathine PCN now, consider LP and Ophthalmology consult 5. Admit to hospital for expedited workup, IV PCN Q4 hours

18 Resurgent Ocular Syphilis West Coast First cases reported December 2014 o Seattle (1/21/15): 6 cases, two leading to blindness o2 cases among sex partners, 5/6 MSM, 3/6 HIV+ oserum RPR 1:256-1:4096; 2 of 3 with CSF results had neurosyphilis o San Francisco (2/20/15): 8 cases o Los Angeles (3/10/15): 2 cases o Also reported in San Diego, Orange, San Mateo, Santa Barbara, Sacramento counties Seattle, King Co Public Health

19 Resurgent Ocular Syphilis West Coast San Francisco Dept. of Public Health

20 Resurgent Ocular Syphilis West Coast With the advent of PrEP and HIV treatment that can suppress viral loads, some people are deciding that they are going to use those methods for HIV prevention and not necessarily reduce their number of partners or use condoms consistently, Susan Phillips, Director of Disease Prevention and Control, SF Dept. of Public Health Wehonews.com

21 Li JZ et al CID 2010;51(4) Ocular Syphilis in HIV+ Patients

22 Syphilis Background (stages) 75% 25% 30% 1º 2º Latent 3º 5-50 years Chancre Rash, fever, HA, malaise Early syphilis if <1 year No Sx Gumma, bone, cardiac, nerve disease Golden M, et al. JAMA. 2003;290:

23 Primary Syphilis - Chancre Photo Courtesy of J. Marrazzo, MD

24 Secondary Syphilis - Rash

25 Secondary Stage - Mucous Patches Photos courtesy of King County STD clinic

26 Syphilis Diagnosis T. pallidum, can t be cultured Darkfield Microscopy Non-Treponemal Tests RPR Rapid Plasma Reagin VDRL Venereal Disease Research Laboratory Treponemal Tests FTA-ABS fluorescent treponemal Ab - absoption TPPA T. pallidum particle agglutination (*NEW*) TP-EIA T. pallidum enzyme immunoassay

27 Syphilis Diagnosis (algorithms) Typical diagnostic algorithm: SCREEN: Non-treponemal test: RPR or VDRL CONFIRM: Treponemal test: FTA-ABS or TP-PA FOLLOW: non-treponemal titer: RPR or VDRL Many labs now incorporating TP-EIA testing due to increased sensitivity, high throughput

28 Low tech vs high tech 180 tests per hour, no manual pipetting

29 Syphilis Reverse Screening Algorithm EIA (Syphilis IgG) used for screening Positive EIA confirmed with RPR & TP-PA RPR titer still used to follow treatment MMWR July 8, (26);

30 Syphilis - Treatment Clinical Stage Treatment Alternative Primary Benzathine PCN G 2.4 million U IM x 1 Secondary Early Latent (<1 yr) Late Latent (> 1 yr) Benzathine PCN G 2.4 million U IM QWeek x 3 Latent (Unk Duration) Late Neurosyphilis Congenital PCN G 4 million U IV Q4 hrs x 14 days PCN G 50,000 U/kg Q8-12 hrs x 14 days Doxycycline 100 mg PO BID x 14d Ceftriaxone 1 g IM QD x 10-14d (same as above) (same as above) Doxycycline 100 mg PO TID x 28d (same as above) (same as above) Procaine PCN G 2.4 million U IM + Probenecid 500 mg PO QID x 14 d Procaine PCN G 50,000 U/kg IM QD x 14 days Source: 2010 CDC STD Treatment Guidelines

31 Syphilis Management Issues Use standard treatment according to STAGE Jarisch-Herxheimer Reaction - Systemic reaction to Syphilis THERAPY - Can occur at all stages of syphilis (90% of 1º, 2º, 50% others) - Self limited; Usually resolves in < 24 hours - TX: Supportive care, reassurance Serologic follow-up - Non-treponemal test (RPR/VDRL) day of treatment as baseline - Repeat at 3, 6, 9, 12, 18, 24 months - Adequate response is 4-fold decline at months

32 Syphilis Management Issues Partner Screening & Treatment (in prior 90 days) - Screen with Syphilis IgG RPR if negative - Benzathine PCN 2.4 million IU x 1 for ALL - Further treatment/evaluation based on individual situation Neurosyphilis - Poorer neurosyphilis treatment response with low CD4, no ARV - CNS invasion occurs in early syphilis regardless of HIV or neurologic symptoms (protein, pleocytosis) - Clinical significance unknown (HIV+/-)

33 Evaluation of CNS in Syphilis, HIV+, 2010 Clinical and CSF consistent with neurosyphilis associated with RPR 1:32 and/or CD Criteria likely sensitive, but non-specific (many negative LPs) - Unless neurologic symptoms present, CSF exam has not been associated with improved clinical outcomes - Guidelines non-directive, LP decision at providers discretion Three approaches: - LP for all HIV+ patients with syphilis, regardless of stage - LP using algorithm based on CD4 and syphilis titer Treat for neurosyphilis if CSF WBC elevated or CSF-VDRL reactive - LP only if symptoms/signs indicate CNS involvement 1. Marra CM, et al. Neurology. 2004;63: Libois A, et al. Sex Transm Dis. 2007;34; Ghanem KG, et al. Clin Infect Dis. 2009; Marra CM et al. Clin Infect Dis. 2008;47:

34 Neurologic/Ophthalmologic Symptoms? No Yes HIV? No Yes CD4<350 or RPR>1:32 RPR >1:32 No Yes No Yes No LP Consider LP LP

35 Syphilis Summary Screening Algorithms may change check your local listings Syphilis Epidemiology has surged in recent years, perhaps fueled by treatment as prevention & PrEP Treat ALL contacts w/benzathine PCN IM x 1 Tell your MSM patients about Syphilis epidemic & screen for Syphilis! Consider LP if any neurologic signs or RPR > 1:32 AND CD4 < 350 Source: PHSKC Sentinel Providers Newsletter 4/2011