S016: Systemic Infections No conflicts for this talk

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1 Adventures in Syphilis Conflict of Interest Disclosure S016: Systemic Infections No conflicts for this talk TED ROSEN, MD PROFESSOR OF DERMATOLOGY BAYLOR COLLEGE OF MEDICINE HOUSTON, TEXAS Objectives Recognize syphilis epidemiology Implement alternative treatments Review unusual syphilis presentations 6 Million cases syphilis/year globally GC, Syphilis Chalmydia Syphilis: Still Dangerous!

2 Current STD Trends Yearly: 20x10 6 new STDs 1 in 4 teenagers acquire STD 1 in 2 sexually active will acquire an STD by age 25 >50% all Americans will have an STD during their lifetime Why STDs? Sex is popularized (TV, movies, music, ads) J Pop Cult 2010;43: STD risks are under-appreciated (except HIV) BMC Public Health 2011;11:727 and Int J Adolesc Med Health 2014;26:203-8 People (all ages) drink and do stupid things BMC Res Notes 2014;7:178 and Am J Public Health. 2012;102: Smoking pot / using drugs leads to risk taking Int J STD AIDS 2013;24: and Am J Addict 2010;19: Older men use ED drugs and acquire STD (3x) Ann Int Med 2010;153:1-7 One night stands & Booty-call relationships J Sex Res 2011;48: Teenagers hook up by sexting Pediatrics 2014;134:e and Pediatrics 2012;130: Anonymous Hook-ups 2

3 APRIL WAS STD AWARENESS MONTH Current STD Trends: Syphilis STDs at unprecedented high rates; as of 2016 > 1993 P&S Syphilis 17.6% 27,814 P&S 8.7 per 100,000 All stages 88,042 an 17.8% Increased in 82% states Congenital lues 27.6% SYPHILIS IS HERE! Syphilis: USA (Rates/100,000) States Localities Louisiana (16.1) Las Vegas (18.8) Nevada (15.4) San Francisco (18.7) California (15.0) New Orleans (18.6) Georgia (13.2) Atlanta (17.8) New York (12.4) Orlando (16.1) Florida (11.9) Los Angeles and San Diego (15.9) Mississippi (10.9) Austin (15.8) North Carolina (10.8) Charlotte, NC and Columbus, OH (15.6) Arizona (10.6) Miami/Ft. Lauderdale/West Palm (15.4) Illinois ( 9.8) Tampa/St. Petersburg (14.7) Syphilis in San Diego? Primary, Secondary: 15.9 per 100,000 6th most syphilitic city in America 3

4 Bicillin Shortages! USA and Canada WHO: Dec, 2017 Countries with bicillin shortage OCT 8, 2016 Early Syphilis: Alternate Rx Options Doxycycline 100mg BID x 14 days Tetracycline 500mg QID x 14 days Ceftriaxone 1-2g IM x days Uncertain efficacy Azithromycin 2.0g, single dose Not in MSM Not in known HIV+ Not in pregnant women Syphilis Treatment: Comparative Study Chinese prospective study primary/secondary lues HIV negative Followup every three months Randomly assigned: Bicillin 2.4MU IM versus Minocycline 100mg BID x 14 or 28 days At the end of two years, ASx and negative serology: Minocycline 100mg BID x 28 days 87.3% Bicillin 2.4MU IM x % Minocycline 100mg BID x 14 days 72.3% Medicine (Baltimore). 2016;95:e5773 4

5 Clinical Tips REMEMBER: SYPHILIS IS RESURGENT! Don t forget to check the oral mucosa - Extragenital chancre (Primarily lip and tongue) Extragenital chancre: 5% Syphilis cases - Mucous patch - Glossitis and Pharyngitis - Condyloma lata - Gumma Oral Surg Oral Med Oral Pathol. 1967;23:45-57 J Am Acad Dermatol. 1985;13:582-4 Extragenital chancre Extragenital chancre Mucous patch Condyloma lata: Oral Mucosa 5

6 Condyloma lata: Oral Mucosa Typical Chancre, Primary Syphilis Bicillin 2.4 x 10 6 Units, IM Solitary, Indurated, Painless Microbes Don t Read Textbooks! Typical + Darkfield RPR +1:4 Annular Syphilid: Peri-orofacial Skin of Color Annular Syphilid: Peri-oroficial 6

7 Immunohistochemistry Syphilis REMEMBER: SYPHILIS IS RESURGENT! Concurrent occurrence of chancre and lesions of secondary lues strongly suggests co-infection with HIV Clin Infect Dis. 2015;61:281-7 Concurrent Primary + Secondary Lues = HIV+ Concurrent Primary + Secondary Lues = HIV+ Chancre (1 0 ) Clin Infect Dis. 2015;61:281-7 Clin Infect Dis. 2015;61:

8 Concurrent Primary + Secondary Lues = HIV+ Chancre (1 0 ) Secondary REMEMBER: SYPHILIS IS RESURGENT! Extreme facial eruption: Think syphilis Nodular syphilis = Florid syphilis Malignant syphilis (Ulcerated, Fever) Clin Infect Dis. 2015;61:281-7 Indian J Dermatol Venereol Leprol. 2015;81:224 An Bras Dermatol. 2014;89:970-2 Int J STD AIDS. 2012;23: Florid Syphilis Lues Maligna This eruption itches This eruption itches If eruption is pruritic, think of eosinophilic folliculitis of HIV 8

9 Case History 13 year-old male Mother brings her son for evaluation of hair loss ASx History: new kitten in household 13 year-old male Mother brings her son for evaluation of hair loss ASx History: new kitten in household Most likely diagnosis? Case History Case History Wood s lamp negative Plucked hairs: Culture negative for fungi Saline moistened sterile swab: Culture negative for fungi Kitten vet exam: Negative NOW WHAT? More history! Do you know about sex? 13 year-old boy having sex with 20 year-old sister Sister is IVDU who trades sex for drugs Sister had rash 4-5 months ago, resolved Case History REMEMBER: SYPHILIS IS RESURGENT! Asymptomatic Hair Loss = Think syphilis Patchy or Moth-eaten Rarely diffuse Generally non-scarring Bx: not characteristic; looks like AA Resolves with antibiotic Rx in 3-4 weeks % of cases of secondary lues Cutis 2005;76:

10 Alopecia of Secondary Syphilis Bicillin 2.4 MU: 4 weeks Sir William Osler Syphilis can simulate virtually every other human disease Osler W. Aequanimitas, 3rd ed, Philadelphia: Blakiston, 1932;