Lisa Villarroel, MD MPH Medical Director, Division of Public Health Preparedness Arizona Department of Health Services Disclosures: None 1
PRIMARY Fitzgerald TJ, Cleveland P, Johnson RC et al: Scanning electron microscopy of Treponema pallidum (Nichols strain) attached to cultured mammalian cells. J Bacteriol 130:1333, 1977. PRIMARY CDC Library 2
PRIMARY CDC PHIL 16750 PRIMARY SECONDARY CDC PHIL 12578 3
PRIMARY SECONDARY CDC Library PRIMARY SECONDARY CDC Picture Cards 4
PRIMARY SECONDARY CDC Library PRIMARY SECONDARY EARLY LATENT 5
PRIMARY SECONDARY EARLY LATENT LATE LATENT PRIMARY SECONDARY EARLY LATENT LATE LATENT 6
EARLY LATE CDC clinical slides 7
NEUROSYPHILIS CAN OCCUR AT EARLY LATE NEUROSYPHILIS CAN OCCUR AT TRANSMISSION TO THE FETUS CAN OCCUR AT. 8
TRANSMISSION TO THE FETUS CAN OCCUR AT. CDC clinical slides TRANSMISSION TO THE FETUS CAN OCCUR AT. CDC PHIL 16750 9
TRANSMISSION TO THE FETUS CAN OCCUR AT. EARLY LATE NEUROSYPHILIS CAN OCCUR AT TRANSMISSION TO THE FETUS CAN OCCUR AT. 10
EARLY LATE 11
Credit: National Archives. EARLY LATE 12
EARLY LATE NEUROSYPHILIS CAN OCCUR AT TRANSMISSION TO THE FETUS CAN OCCUR AT. 13
RATE 14
PRIMARY & SECONDARY SYPHILIS CASES MEN WHO HAVE SEX WITH MEN MEN WHO HAVE SEX WITH WOMEN PRIMARY & SECONDARY SYPHILIS CASES MEN WHO HAVE SEX WITH MEN MEN WHO HAVE SEX WITH WOMEN WOMEN 15
PRIMARY & SECONDARY SYPHILIS RATE / 100,000 ARIZONA U.S. 2007 2010 2013 2016 PRIMARY & SECONDARY SYPHILIS CASES IN ARIZONA 2012 2013 2014 2015 2016 16
PRIMARY & SECONDARY SYPHILIS RATE / 100,000 BLACK (24) AMERICAN INDIAN HISPANIC WHITE ASIAN (4.5) 2012 2013 2014 2015 2016 CONGENITAL SYPHILIS CASES & RATES / 100,00 30 ARIZONA 20 CASE RATE U.S. CASE RATE 15 10 0 2012 2013 2014 2015 2016 0 17
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SYMPTOM RECOGNITION PRIMARY SECONDARY EARLY LATENT LATE LATENT SYMPTOM RECOGNITION 19
PRIMARY SECONDARY EARLY LATENT LATE LATENT SYMPTOM RECOGNITION CDC Syphilis Images PRIMARY SECONDARY EARLY LATENT LATE LATENT SYMPTOM RECOGNITION Joe Engelman, SF City Clinic 20
SYMPTOM RECOGNITION EARLY LATE SYMPTOM RECOGNITION CDC Syphilis Images 21
SYMPTOM RECOGNITION CDC Syphilis Images EARLY LATE NEUROSYPHILIS CAN OCCUR AT Review of Ophthal,, 2008 22
NEUROSYPHILIS CAN OCCUR AT Review of Ophthal,, 2008 EARLY LATE SCREEN 23
EARLY LATE 24
EARLY LATE LABORATORY TESTING 25
NONTREPONEMAL TESTS RPR, VDRL TREPONEMAL TESTS TPPA, FTA-ABS CIA, EIA (NEW) TIME OF INFECTION WEEKS TIME POST-INFECTION YEARS 26
TREPONEMAL TESTS (TPPA, FTA-ABS) TIME OF INFECTION WEEKS TIME POST-INFECTION YEARS TREPONEMAL TESTS (TPPA, FTA-ABS) UNTREATED NONTREPONEMAL TESTS (RPR, VDRL) TREATED TIME OF INFECTION WEEKS TIME POST-INFECTION YEARS 27
NONTREPONEMAL TESTS RPR, VDRL FOLLOWS RESPONSE TO TREATMENT 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 28
2-FOLD CHANGE 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 2-FOLD CHANGE 1:1 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 1:512 1:1024 4-FOLD CHANGE [SIGNIFICANT] 29
NONTREPONEMAL TESTS RPR, VDRL FOLLOWS RESPONSE TO TREATMENT CAN VARY DAILY EARLY LATE NONTREPONEMAL TESTS RPR, VDRL FOLLOWS RESPONSE TO TREATMENT CAN VARY DAILY ARE FALSE POSITIVES 30
NONTREPONEMAL TESTS RPR, VDRL FOLLOWS RESPONSE TO TREATMENT CAN VARY DAILY ARE FALSE POSITIVES ARE RARE FALSE NEGATIVES EARLY LATE TREPONEMAL TESTS TPPA, FTA-ABS, CIA/EIA. 31
TREPONEMAL TESTS TPPA, FTA-ABS, CIA/EIA GOOD, EARLY PERFORMANCE. REACTIVITY PERSISTS OVER TIME EARLY LATE TREPONEMAL TESTS TPPA, FTA-ABS, CIA/EIA GOOD, EARLY PERFORMANCE. REACTIVITY PERSISTS OVER TIME LESS FALSE POSITIVES (FTA, EIA MAIN PROBLEM) 32
NONTREPONEMAL TESTS RPR, VDRL TREPONEMAL TESTS TPPA, FTA-ABS, CIA/EIA. EARLY LATE NONTREPONEMAL TESTS RPR, VDRL TREPONEMAL TESTS TPPA, FTA-ABS, CIA/EIA. 33
TRADITIONAL NONTREPONEMAL (RPR) Am J OB and GYN, April 2017 TRADITIONAL NONTREPONEMAL (RPR) Am J OB and GYN, April 2017 34
TRADITIONAL NONTREPONEMAL (RPR) TREPONEMAL Am J OB and GYN, April 2017 TRADITIONAL NONTREPONEMAL (RPR) TREPONEMAL Am J OB and GYN, April 2017 35
TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL Am J OB and GYN, April 2017 TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL Am J OB and GYN, April 2017 36
TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL NONTREPONEMAL (RPR) Am J OB and GYN, April 2017 TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL NONTREPONEMAL (RPR) TREPONEMAL (TPPA) Am J OB and GYN, April 2017 37
TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL NONTREPONEMAL (RPR) TREPONEMAL (TPPA) Am J OB and GYN, April 2017 TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL NONTREPONEMAL (RPR) TREPONEMAL (TPPA) Am J OB and GYN, April 2017 38
TRADITIONAL NONTREPONEMAL (RPR) REVERSE TREPONEMAL (EIA/CIA) TREPONEMAL NONTREPONEMAL (RPR) TREPONEMAL (TPPA) Am J OB and GYN, April 2017 EARLY LATE STAGING 39
SYMPTOMS = PRIMARY / SECONDARY STAGES EARLY LATE NO SYMPTOMS = LATENT STAGES 40
NO SYMPTOMS = LATENT STAGES EARLY IF IN PAST YEAR NEG SYPHILIS SEROLOGY LATE IF IN PAST YEAR (NONE OF THOSE) KNOWN CONTACT TO EARLY CASE OF SYPHILIS HISTORY OF SYMPTOMS SUSTAINED 4x INCREASE ONLY POSSIBLE EXPOSURE EARLY LATE 41
SYMPTOM RECOGNITION 42
SYMPTOM RECOGNITION EMPIRICALLY TREAT EARLY LATE SYMPTOM RECOGNITION EMPIRICALLY TREAT PARTNERS WITHIN 90 DAYS EMPIRICALLY TREAT 43
EARLY LATE TREATMENT NEEDED? GET HISTORY 44
PRIMARY SECONDARY EARLY LATENT LATE LATENT SYMPTOM RECOGNITION EMPIRICALLY TREAT TREATMENT NEEDED? GET HISTORY PARTNERS WITHIN 90 DAYS EMPIRICALLY TREAT EARLY LATE BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM x 1, ONCE 45
BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM x 1, ONCE BENZATHINE PENICILLIN G 2.4 MILLION UNITS IM x 3, Q WEEK EARLY LATE DAY OF TREATMENT CHECKLIST 46
DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). EARLY LATE DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). RPR 1:1024 RPR 1:256 [NOT CHECKED] RPR 1:256 DAY OF INITIAL LAB TEST DAY OF TREATMENT DAY OF FOLLOW UP 47
DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). WARN ABOUT JARISCH-HERXHEIMER. EARLY LATE DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). WARN ABOUT JARISCH-HERXHEIMER. COUNSEL NO SEX x 1 WEEK. 48
DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). WARN ABOUT JARISCH-HERXHEIMER. COUNSEL NO SEX x 1 WEEK. ADVISE THAT ALL PARTNERS BE EVALUATED. EARLY LATE DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). WARN ABOUT JARISCH-HERXHEIMER. COUNSEL NO SEX x 1 WEEK. ADVISE THAT ALL PARTNERS BE EVALUATED. CONFIRM HAS BEEN TESTED FOR HIV. 49
DAY OF TREATMENT CHECKLIST GET A TITER (REALLY). WARN ABOUT JARISCH-HERXHEIMER. COUNSEL NO SEX x 1 WEEK. ADVISE THAT ALL PARTNERS BE EVALUATED. CONFIRM HAS BEEN TESTED FOR HIV. ESTABLISH FOLLOW-UP EXPECTATIONS. EARLY LATE FOLLOW UP 50
FOLLOW UP SEROLOGIC TESTS ~Q6 MONTHS. HIV (-) HIV (+) PRIMARY / SECONDARY SYPHILIS 6, 12 MONTHS 3, 6, 9, 12, 24 MONTHS EARLY LATENT / LATE LATENT SYPHILIS 6, 12, 24 MONTHS 6, 12, 18, 24 MONTHS EARLY LATE FOLLOW UP SEROLOGIC TESTS ~Q6 MONTHS. TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO. 51
FOLLOW UP SEROLOGIC TESTS ~Q6 MONTHS. TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO. SUSPECTED TREATMENT FAILURE OR REINFECTION IF: 4-FOLD INCREASE IN TITERS OR NEWLY SYMPTOMATIC OR TITERS DON T DECLINE EARLY LATE FOLLOW UP SEROLOGIC TESTS ~Q6 MONTHS. TREATMENT RESPONSE: 4X TITER DECLINE BY 12 (P/S) OR 24 MO. SUSPECTED TREATMENT FAILURE OR REINFECTION IF: 4-FOLD INCREASE IN TITERS OR NEWLY SYMPTOMATIC OR TITERS DON T DECLINE NEW HIV TEST? LP for CSF VDRL? RETREAT (BICILLIN x3) 52
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DATA DATA PARTNERS 54
DATA PARTNERS POLICY DATA PARTNERS POLICY ANSWERS 55
DATA PARTNERS POLICY ANSWERS DATA PARTNERS POLICY ANSWERS CALL PUBLIC HEALTH 56
. EARLY LATE. 57
lisa.villarroel@azdhs.gov ACKNOWLEDGEMENTS Joseph Engelman Kristen Herrick Susan Robinson Stephanie Cohen Laura Dalton Paul Bloomquist CAPTC Roxanne Ereth Rebecca Scranton Tymeckia Kendall Don Herrington 58
EXTRA SLIDES 59
Rac Syphilis in Pregnancy OB GYN 60
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STAGE STARTS LASTS (untreated) Other sxs Infectivity Primary 10d 12 weeks after inoculation (median time 21 d) Secondary 2 8 weeks after chancre heals or 4 8 weeks after onset of chancre can overlap with 1ary Early Latent After resolution of 2ary symptoms 1 6 weeks Papule >Chancre Nontender regional adenopathy Several weeks symmetric, bilateral rash mucous patches/condyloma lata fever, headache, pharyngitis hepatitis, osteitis, glomerulonephritis meningitis/ocular/oto Until 1 year after inoculation can alternate with 2ary Late Latent 1 year after inoculation Until treatment or development of late symptomatic disease Late Symptomatic 15 25 years after inoculation Neurologic: meningitis, ocular, oto, meningovascular (strokes) Until treatment General paresis (CNS parenchyma) Tabes dorsalis (posterior columns: sensory/proprio) Cardiac (aortitis, infarction) Late benign (gummatous) Infectious by direct contact or blood Infectious by direct contact (when mucosal lesions present) or blood Infectious by direct contact (when mucosal lesions present) or blood Infectious by blood Ghanem. CNS Neuroscience & Therapeutics 2010;6(5): e157-68 62
Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you. William Osler, 1909 Syphilis remains the despair of the statistician. -- William Osler, 1917 When it comes to syphilis, suspect your grandmother William Osler The souls of infants born only to die or suffer, cry out against the infamy of uncured syphilis. (well known venereal syphilologist) With our present appropriations, Federal and State and private, we might just as well try to empty the Pacific Ocean with a teaspoon. Dr. OC Wenger, 1926 63