Cases. A Case of Primary Syphilis: Emergency Department Evaluation and Management

Transcription

1 Cases O F N O T E Advanced Emergency Nursing Journal Vol. 30, No. 4, pp Copyright c 2008 Wolters Kluwer Health Lippincott Williams & Wilkins Column Editor: Elda G. Ramirez, PhD, RN, FNP-BC, FAANP A Case of Primary Syphilis: Emergency Department Evaluation and Management Courtney Elizabeth Reinisch, DNP; Janice L. Smolowitz, EdD, DNP, APN Abstract Syphilis is a systemic disease caused by Treponema pallidum spirochete. The majority of young, sexually active patients who have genital ulcers also have genital herpes, syphilis, or chanroid. Syphilis is therefore known as the great imitator because many of the characteristics of syphilis are indistinguishable from those of other sexually transmitted infections. Patients who contract syphilis may seek treatment of related complaints on the basis of varying stages of infection. It is important for the advance practice nurse to screen, diagnose, and appropriately treat all patients at risk for syphilis and other sexually transmitted infections. This article presents an interesting case of a 21-year-old man with a genital lesion who presented to the emergency department. The role of the emergency department advance practice nurse in the treatment and management of patients with syphilis is outlined herein. Key words: chancre, genital ulcer, primary syphilis, sexual transmitted infection (STI), sexually transmitted disease (STD) EPIDEMIOLOGY In the United States, the majority of young, sexually active patients who have genital ulcers have genital herpes, syphilis, or chanroid. The frequency of each condition differs by geographic area and patient population; however, genital herpes is the most prevalent of these diseases. More than one of these diseases can be present in a patient who has genital ulcers. All three of these diseases have From the School of Nursing, Columbia University, New York. Corresponding author: Courtney Elizabeth Reinisch, DNP, School of Nursing, Columbia University, New York, NY ( cer2117@columbia.edu). been associated with an increased risk for HIV infection. The overall increase in rates of syphilis among adults and adolescents from 2004 to 2005 was driven primarily by increases among men having sex with men (MSM), with the rate increasing 8.5% (from 4.7 in 2004 to 5.1 per 100,000 populations in 2005). Trends were also seen among women, as the rate of reported cases increased for the first time in more than 10 years. Primary and secondary syphilis rates increased among African Americans for the second year in 2005 after a decade of decline (Centers for Disease Control and Prevention [CDC], Workowski, & Berman, 2006). Among 18- to 49-year-olds in the United States, the prevalence of syphilis 310

2 October December 2008 Vol. 30, No. 4 Primary Syphilis in the Emergency Department 311 seroreactivity was 0.71% with Blacks having the highest rate of seroprevalence at 4.3%, followed by Mexican Americans 0.98% and Whites 0.07%. Syphilis seroprevalence was higher among those who had first sex before the age of 15 years and among those persons who reported greater than five lifetime sex partners (Gottlieb et al., 2008). PATHOPHYSIOLOGY Syphilis is a systemic disease caused by Treponema pallidum spirochete. Treponema pallidum readily crosses intact mucosa (Fig 1). The route of transmission of syphilis is by sexual contact, although there are cases of congenital syphilis via transmission in utero (CDC, Workowski, & Berman, 2006). The incubation period from contact to infection for syphilis ranges from 9 to 90 days, usually about 21 days. The infection devel- ops at site of contact. Typically the initial presentation is a single, painless, clean-based, indurated ulcer with firm raised borders. See Table 1 for a description of the different stages of syphilis. THE CASE A 21-year-old African American man with a chief complaint of recheck of a rash presented to a suburban community hospital emergency department (ED). The patient stated that he was diagnosed and treated for scabies 5 days earlier at a health center. He reported that he applied permethrin lotion and left it on overnight before washing it off. According to the patient, my rash and itching improved. Three days ago he noticed a painless pimple on his penis. He was sexually active with only women and used protection (e.g., condoms) all the time. The patient denied having a serious girlfriend or being in a committed relationship. The patient also stated that it had been a long time since he had intercourse without wearing a condom although he was unable to specify how long it had been. Review of Systems The patient denied fever, fatigue, recent weight loss, weakness, headache, seizures, gait abnormities, paralysis, heat or cold intolerance, excessive sweating, or excessive thirst or hunger. He stated that he had noticed swollen lymph nodes in the groin. The patient denied any urinary frequency, urgency, hesitancy, hematuria, or penile discharge. Figure 1. Chancre of primary syphilis. From Greenberg s Text-Atlas of Emergency Medicine, by M. I. Greenberg, R. G. Hendrickson, M. Silverberg, C. J. Capbell, A. P. Morocco, C. A. Salvaggio, et al., 2005, Philadelphia, PA: Lippincott Williams & Wilkins, p Reprinted with permission of Sweet and Gibbs. Medical History The patient s medical history was significant for scabies and varicella as a child. Pasthospitalizations and surgeries. None Allergies. No known allergies to food or medications Immunizations. Tetanus immunization was 7yearsago Current medications. None

3 312 Advanced Emergency Nursing Journal Table 1. Signs and symptoms of syphilis infection Syphilis infection Primary infection Secondary infection Tertiary infection Signs and symptoms Ulcer or chancre at the infection site Single ulcerated lesion with a surrounding red areola. The edge and base have a cartilaginous consistency on palpation. 70% of men present with lesion on penis or scrotum 50% of women present with lesion on the vulva, cervix, or perineum Extra genital chancres occur most commonly above the neck, usually involving the lips or oral cavity Regional lymph nodes are firm, discrete, and nontender Abrading the chancre releases highly infectious clear exudate containing numerous Treponema pallidum organisms Manifestations that include, but are not limited to, skin rash, mucocutaneous lesions, and lymphadenopathy Patchy alopecia Cardiac or ophthalmic manifestations, auditory abnormalities, or gummatous lesions Note. Adapted from Sexually Transmitted Diseases Treatment Guidelines, by K. A. Workowski and S. M. Berman, 2006, Morbidity and Mortality Weekly Report. Social History The patient was a full-time college student. He lived in an apartment with three male roommates. The patient denied alcohol abuse; he stated, I drink alcohol socially on weekends at college, approximately six to twelve beers per week. He denied any recreational drug use. The patient stated he was a smoker approximately one half pack of cigarettes daily for the last 4 years (two pack years). Family History The family history was significant for hypertension, diabetes, cardiovascular disease, renal disease, and stroke. There was no history of seizure disorder or cancer. Physical Examination The physical examination revealed that a 21- year-old African American man appeared to be his stated age. He was in no acute distress. His affect and mood were anxious. Vital signs were blood pressure 138/72 mmhg, pulse rate 92/min, respirations 20/min, temperature 97.9 F by mouth, pain 0, and oxygen saturation 99% on room air. Pertinent positive physical findings were a painless 1-cm reddened, raised lesion to the glans of the penis without bleeding or drainage, testicles without masses, and no penile discharge noted (see Fig 1). Lymphatic examination revealed three enlarged, nontender inguinal nodes bilaterally ranging in size from 0.5 to 1.5 cm. Neurologic examination revealed the patient to be alert and oriented to person, place, and time. Cranial nerves II XII were without abnormality. Motor function for upper and lower extremities was equal bilaterally, strength was 5/5 bilaterally, and deep tendon reflexes were +2 bilaterally. DIFFERENTIAL DIAGNOSIS The history, physical examination, and risk factors made primary syphilis the most likely diagnosis for this patient. Consideration was given to chancroid and herpes simplex virus; however, in the absence of pain, herpes simplex virus was less likely. Table 2 lists the differential diagnoses considered for patients who present with genital lesions.

4 October December 2008 Vol. 30, No. 4 Primary Syphilis in the Emergency Department 313 Table 2. Differential diagnosis for syphilis Amyloidosis Lichen Chancroid Condyloma acuminata Herpes simplex Leprosy Lymphogranuloma venereum Genital warts Rubella Acute febrile exanthem Infectious mononucleosis Drug eruptions Erythema multiforme Pityriasis rosea Pityriasis rubra pilaris Psoriasis Sarcoidosis Scabies Stevens-Johnson syndrome Tinea corporis Lichen planus Oral thrush Note. Adapted from Sexually Transmitted Diseases Treatment Guidelines, by K. A. Workowski and S. M. Berman, 2006, Morbidity and Mortality Weekly Report. LABS A diagnosis based only on the patient s medical history and physical examination frequently is inaccurate. Therefore, all patients who have genital ulcers should be examined with a serologic test for syphilis and a diagnostic evaluation for genital herpes. In settings where chancroid is prevalent, a test for Haemophilus ducreyi should also be performed. Dark field examinations and direct fluorescent antibody tests of lesion exudates or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis is possible with the use of two types of serologic tests: (1) nontreponemal tests (e.g., Venereal Disease Research Laboratory and rapid plasma reagin) and (2) treponemal tests (e.g., fluorescent treponemal antibody absorption and T. pallidum particle agglutination). The use of only one type of serologic test is insufficient for diagnosis because false-positive nontreponemal test results are sometimes associated with various medical conditions Table 3. Diagnostic tests recommended for evaluation of genital ulcers Syphilis Herpes Chancroid Specific tests for evaluation of genital ulcers Serology and either darkfield examination or direct immunofluorescence test for Treponema pallidum Culture or antigen test for herpes simplex virus Culture for Haemophilus ducreyi Note. Adapted from Sexually Transmitted Diseases Treatment Guidelines, 2006, by Centers for Disease Control and Prevention, K. A. Workowski, and S. M. Berman, 2006, Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), pp unrelated to syphilis (CDC, Workowski, & Berman, 2006). Table 3 identifies needed evaluation for genital ulcers and Table 4 discusses diagnostics specific to syphilis. A rapid plasma reagin was drawn for serologic evaluation for syphilis. Although the patient lacked dysuria and signs of urethritis, screening for chlamydia, gonorrhea, and human immunodeficiency virus (HIV) infection were indicated. Gonorrhea and chlamydia cultures were obtained. HIV testing was not performed in the ED because the patient was uninsured, posttest counseling was not available in this setting, and referral to the sexual transmitted infection (STI) clinic provided a comprehensive follow-up. Treatment Patients who have syphilis may seek treatment of signs or symptoms of related complaints on the basis of varying stages of infection. This patient presented 3 days after symptoms began. The patient was treated empirically, with penicillin G benzathine (Bicillin L-A) (2.4 units im), the treatment of choice for syphilis.

5 314 Advanced Emergency Nursing Journal Table 4. Diagnostic evaluation for syphilis Primary and secondary infection In suspected acquired syphilis, perform nontreponemal serology screening using VDRL, RPR, or the recently developed ICE syphilis recombinant antigen test Dark-field microscopy is essential in evaluating moist cutaneous lesions Direct immunofluorescence staining of fixed smears (direct fluorescent antibody Treponema pallidum) is an option Both procedures detect the causative organism at a rate of approximately 85% 92% Test sera yielding a positive or equivocal reaction by the fluorescent treponemal antibody-absorption, quantitative VDRL/RPR, and microhemagglutination assay Treponema pallidum tests Primary syphilis: Skin lesions reveal perivascular infiltration, chiefly by lymphocytes, plasma cells, and macrophages, with capillary endothelial proliferation and subsequent obliteration of small blood vessels Tertiary infection Biopsy may be necessary to differentiate gummas from coincidental granulomatous conditions Lumbar puncture for cerebrospinal fluid examination is indicated with neurologic signs or symptoms, treatment failure or plans to administer treatment other than penicillin, a serum reagin titer of greater than or equal to 1:32, seropositive HIV, and other changes indicative of active syphilis (e.g., gumma, aortitis) The only means by which the occurrence of asymptomatic neurosyphilis in latent syphilis can be excluded is via cerebrospinal fluid examination Note: VDRL = Venereal Disease Research Laboratory; RPR = rapid plasma reagin. Adapted from Sexually Transmitted Diseases Treatment Guidelines, 2006, by Centers for Disease Control and Prevention, K. A. Workowski, and S. M. Berman, 2006, Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), pp Penicillin G, administered parenterally, is the preferred drug for treatment of all stages of syphilis. The preparation(s) used (i.e., benzathine, aqueous procaine, or aqueous crystalline), the dosage, and the length of treatment depend on the stage and clinical manifestations of the disease. However, neither combinations of benzathine penicillin and procaine penicillin nor oral penicillin preparations are considered appropriate for the treatment of syphilis (CDC, Workowski, & Berman, 2006). No proven alternatives to penicillin are available for treating neurosyphilis, congenital syphilis, or syphilis in pregnant women. Penicillin is also recommended for use, whenever possible, in HIV-infected patients (CDC, Workowski, & Berman, 2006). Of the adult U.S. population, 3% 10% have experienced urticaria, angioedema, or anaphylaxis (i.e., upper airway obstruction, bronchospasm, or hypotension) after penicillin therapy. Readministration of penicillin to these patients can cause severe, immediate reactions. Because anaphylactic reactions to penicillin can be fatal, every effort should be made to avoid administering penicillin to penicillin-allergic patients, unless they undergo acute desensitization to eliminate anaphylactic sensitivity (CDC, Workowski, & Berman, 2006). An estimated 10% of persons who report a history of severe allergic reactions to penicillin remain allergic. There are limited research data to support the use of alternatives to penicillin in early syphilis. Nonpregnant individuals with definite penicillin allergy and primary or secondary syphilis can be effectively treated with an alternative regimen of doxycycline, in a dosage of 100 mg

6 October December 2008 Vol. 30, No. 4 Primary Syphilis in the Emergency Department 315 orally twice daily for 14 days or tetracycline HCl 500 mg orally 6 hourly for 14 days. Doxycycline is generally better tolerated than an equivalent tetracycline regimen, which may enhance treatment compliance. Erythromycin, in a dosage of 500 mg orally four times daily for 2 weeks, is a second alternative, although it is not as effective as doxycycline. Evidence for the effectiveness of ceftriaxone (Rocephin) is limited but a regimen of 1 g daily, given intramuscularly or intravenously for 8 10 days, may maintain adequate treponemacidal levels. Azithromycin 2 g as a single oral dose may be effective. Careful monitoring of the serologic response is necessary to ensure eradication of the organism whenever an alternative regimen is used (Workowski & Berman, 2006). COUNSELING The patient was counseled regarding the diagnosis of syphilis, risks for STI, prevention, and need for HIV testing. The patient was also advised that he is at highest risk for this condition on the basis of his age, race, sexual practices, college student status, and high-risk behavior that included heavy alcohol use on weekends. The patient was referred to the local sexually transmitted disease (STD) clinic for follow-up within 72 hr where he would receive results of ED diagnostics, further treatment if needed, HIV counseling and testing, and partner management using a sliding fee scale. PREVENTION OF STIs Primary prevention of STIs begins with changing the sexual behaviors that place persons at risk for infection. Healthcare providers have a unique opportunity to provide education and counseling to their patients. As part of the clinical interview, healthcare providers should routinely obtain sexual histories from their patients and address risk reduction (CDC, Workowski, & Berman, 2006). Counseling skills, characterized by respect, Table 5. Key techniques to facilitate rapport with patients Open-ended questions Key techniques to facilitate rapport with patients Understandable language Normalizing language Tell me about any new sex partners you ve had since your last visit. What s your experience with using condoms been like? Have you ever had a sore or scab on your penis? Some of my patients have difficulty using a condom with every sex act. How is it for you? Note. Adapted from Sexually Transmitted Diseases Treatment Guidelines, 2006, by Centers for Disease Control and Prevention, K. A. Workowski, and S. M. Berman, 2006, Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), pp compassion, and a nonjudgmental attitude toward all patients, are essential to obtaining a thorough sexual history and to delivering prevention messages effectively, outlined in Table 5. The Five Ps Open communication with patients is necessary when gathering information and educating to prevent the spread of STIs. The CDC, Workowski, and Berman (2006) identify the five key areas of interest as the Five Ps partners, prevention of pregnancy, protection from STDs, practices, and past history of STD. Eliciting information concerning five key areas of interest is outlined in Table 6. Abstinence The most reliable way to avoid transmission of STDs is to abstain from sex (i.e., oral, vaginal, or anal sex) or to be in a long-term, mutually monogamous relationship with an

7 316 Advanced Emergency Nursing Journal Table 6. The five Ps: Patient interview questions The five Ps: Partners, prevention of pregnancy, protection from STDs, practices, past history of STDs Partners Prevention of pregnancy Protection from STDs Practices Past history of STDs Do you have sex with men, women, or both? In the past 2 months, how many partners have you had sex with? In the past 12 months, how many partners have you had sex with? Are you or your partner trying to get pregnant? If no, What are you doing to prevent pregnancy? What do you do to protect yourself from STDs and HIV? To understand your risks for STDs, I need to understand the kind of sex you have had recently. Have you had vaginal sex, meaning penis in vagina sex? If yes, Do you use condoms: never, sometimes, or always? Have you had anal sex, meaning penis in rectum/anus sex? If yes, Do you use condoms: never, sometimes, or always? Have you had oral sex, meaning mouth on penis/vagina? For condom answers If never : Why don t you use condoms? If sometimes : In what situations or with whom, do you not use condoms? Have you ever had an STD? Note. STD = sexually transmitted disease. Adapted from Sexually Transmitted Diseases Treatment Guidelines, 2006, by Centers for Disease Control and Prevention, K. A. Workowski, and S. M. Berman, 2006, Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), pp uninfected partner. Counseling that encourages abstinence from sexual intercourse is crucial for persons who are being treated for an STD (or whose partners are undergoing treatment) and for persons who want to avoid the possible consequences of sex completely (e.g., STD/HIV and unintended pregnancy; CDC, Workowski, & Berman, 2006). Because the incidence of syphilis has increased in HIV-infected persons, the use of client-centered STD counseling for HIVinfected persons has received strong emphasis from public health agencies. All patients who have syphilis should be tested for HIV infection, and in geographic areas where the prevalence of HIV is high, patients who have primary syphilis should be retested for HIV after 3 months if the first HIV test result was negative (CDC, Workowski, & Berman, 2006). More than 60% of new syphilis infections are estimated to occur in MSM (Gottlieb et al., 2008). Condom Education Patients should be advised that condoms must be used consistently and correctly to be effective in preventing STIs. The recommendations in Table 7 ensure the proper use of male condoms. Patient Follow-up Treatment failure can occur with any regimen. Assessing response to treatment frequently is difficult, and definitive criteria for cure or failure have not been established. Nontreponemal test titers might decline more slowly for persons who previously had syphilis. Patients should be reexamined clinically and serologically 6 and 12 months after treatment; more frequent evaluation might be prudent if follow-up is uncertain (CDC, Workowski, & Berman, 2006). Patients who have persistent signs or recurrent symptoms or who have a sustained

8 October December 2008 Vol. 30, No. 4 Primary Syphilis in the Emergency Department 317 Table 7. Patient education: Condom use Use a new condom with each sex act (e.g., oral, vaginal, and anal) Carefully handle the condom to avoid damaging it with fingernails, teeth, or other sharp objects Put the condom on after the penis is erect and before any genital, oral, or anal contact with the partner Use only water-based lubricants (e.g., K-Y Jelly, Astroglide, AquaLube, and glycerin) with latex condoms. Oil-based lubricants (e.g., petroleum jelly, shortening, mineral oil, massage oils, body lotions, and cooking oil) can weaken latex Ensure adequate lubrication during vaginal and anal sex, which might require the use of exogenous water-based lubricants To prevent the condom from slipping off, hold the condom firmly against the base of the penis during withdrawal and withdraw while the penis is still erect Note. Adapted from Sexually Transmitted Diseases Treatment Guidelines, 2006, by Centers for Disease Control and Prevention, K. A. Workowski, and S. M. Berman, 2006, Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), pp fourfold increase in nontreponemal test titer have probably failed treatment or were reinfected. These patients should be retreated and reevaluated for HIV infection. Treatment failure usually cannot be reliably distinguished from reinfection with T. pallidum; therefore, a cerebrospinal fluid analysis should also be performed (CDC, Workowski, & Berman, 2006). Partner Management Partner notification is the process by which healthcare providers or public health authorities can seek information and help arrange for evaluation and treatment of sex partners, either directly or with assistance from state and local health departments. The intensity of partner services and the specific STIs for which they are offered vary among providers, agencies, and geographic areas. These services should be accompanied by health counseling and might include referral of patients and their partners for other services (CDC, Workowski, & Berman, 2006). Public Health Implications Sexual contact without barrier protection is the second highest cause of the global burden of disease. Twelve million people per year acquire syphilis, primarily in Africa, where congenital syphilis is a major cause of still birth (Peterman & Furness, 2007). Because syphilis is on the rise in particular groups, public health efforts need to continue. Prevention efforts include information campaigns aimed at MSM of the risk of syphilis (Peterman & Furness, 2007). An urgent need exists to amplify effective use of evidence-based measures to diminish this burden of disease, including barrier methods that protect against both STI and pregnancy (male and female condoms). The limited effect of public health campaigns to promote effective use of these barrier methods might be attributable to scare tactics that emphasize adverse consequences of sexual acts without protection. Promotion of pleasure in use of male and female condoms can facilitate consistent use of condoms and boost their effectiveness to protect against STI and pregnancy (Philpott, Knerr, & Maher, 2006). Therefore, the effect of public-health initiatives that emphasize positive outcomes of use of male and female condoms as barrier methods, and positive results of practicing other forms of safer sex, need to be investigated (Philpott, Knerr, & Maher, 2006). Such work includes the potential for safer sex to contribute to good health and hygiene in general, to reduce anxiety about risk of STI and pregnancy, and make sex more pleasurable (Philpott, Knerr, & Maher, 2006). FUTURE RECOMMENDATIONS AND CONCLUSION This patient was treated and discharged from the ED uneventfully. He was counseled and

9 318 Advanced Emergency Nursing Journal educated appropriately and verbalized understanding of the importance for STI evaluation at the local clinic. He planned to discuss his diagnosis with his sexual partner so that she could undergo evaluation and treatment. Patients who contract syphilis may seek treatment in the ED setting. Advance practice nurses need to be aware that syphilis is once again rising in prevalence and to be vigilant for individuals at increased risk for this infection, such as Blacks and MSM. Partners may also present in the ED and require screening, treatment, and counseling. Advance practice nurses need to be aware that treatment failure can occur and to be certain to retreat or refer patients appropriately. The advance practice nurse in the ED is in a position to identify, appropriately treat, educate, counsel, and refer these patients for continued care to avoid a further spread and rise in infection rates. REFERENCES Centers for Disease Control and Prevention, Workowski, K. A., & Berman, S. M. (2006). Sexually transmitted diseases treatment guidelines, [erratum appears in MMWR Recommendations and Reports, 15;55(36):997.] Morbidity and Mortality Weekly Report Recommendations and Reports, 55(RR-11), Gottlieb, S. L., Pope, V., Sternberg, M. R., McQuillan, G. M., Beltrami, J. F., Berman, S. M., et al. (2008). Prevalence of syphilis seroreactivity in the United States: Data from the National Health and Nutrition Examination Surveys (NHANES) Sexually Transmitted Diseases, 35(5), Greenberg, M. I., Hendrickson, R. G., Silverberg, M., Capbell, C. J., Morocco, A. P., Salvaggio, C. A., et al. (2005). Greenberg s text-atlas of emergency medicine. Philadelphia, PA: Lippincott Williams & Wilkins. Peterman, T. A., & Furness, B. W. (2007). The resurgence of syphilis among men who have sex with men. Current Opinion in Infectious Diseases, 20(1), Philpott, A., Knerr, W., & Maher, D. (2006). Promoting protection and pleasure: Amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy. Lancet, 368(9551), Workowski, K. A., & Berman, S. M. (2006). Sexually transmitted diseases treatment guidelines. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. (Recommendations and reports ISSN No )