International AIDS Society-USA

Presentation

Syphilis in the HIV-Infected Patient
Jeanne M. Marrazzo, MD, MPH

Level: Advanced

You must answer at least 6 of 8 questions correctly to receive a passing score (≥75%) and earn continuing medical education credit.

Case for Questions 1 through 7

A 45-year-old man comes to your office for his initial visit to establish HIV care. The patient learned he was HIV-infected when a test recently obtained at a community sexually transmitted disease (STD) center came back positive; he has sought testing every 6 months for the past several years. The patient thinks that he became infected because of a recent unprotected sexual encounter with a new partner he met online, and with whom he only had sex once, approximately 3 months ago. He reports having receptive and insertive oral and anal intercourse without a condom. He has not had any sexual partners since the encounter, and today is the first time he has sought care. He is currently asymptomatic and feels physically well. His physical examination is normal, including assessment of his external genitalia. His last STD screening occurred at a local STD clinic approximately 6 months ago, where, he reports, “they took my blood and tested me for everything and said I had no problems.”

1. Which of the following tests should be performed as part of routine screening for STDs in this patient?

a. Syphilis serologic testing

b. Neisseria gonorrhoeae testing of the pharynx

c. Chlamydia trachomatis testing of the pharynx

d. Urine nucleic acid amplification test (NAAT) for C trachomatis and N gonorrhoeae

Select one of the following:

1. a, b, and c

2. a and b

3. a, b, and d

4. all of the above

2. Which of the following assays can be used to screen for rectal infection with C trachomatis in this patient?

a. Cell culture

b. Direct fluorescent antibody (DFA)

c. Enzyme immunoassay (EIA)

d. Urine nucleic acid amplification test (NAAT) if validated by a local laboratory

e. Anal Papanicolaou (PAP) test

Select one of the following:

1. c

2. a or b

3. a or d

4. c or d

5. any of the above

3. The patient’s serum Venereal Disease Research Laboratory (VDRL) test returns positive and is confirmed with a Treponema pallidum particle agglutination (TPPA) test, which is also reactive. His serum VDRL titer is 1:64. Which of the following statements regarding these findings is true?

a. Even though the patient is asymptomatic, it is very likely that he has acquired a recent infection with T pallidum, the causative agent of syphilis.

b. Because the patient is asymptomatic, both tests need to be confirmed with the recently developed EIA for syphilis.

c. The relatively high serum VDRL titer does not suggest remote acquisition of syphilis (for example, several years ago).

d. A serum VDRL titer above 1:16 places this patient at increased risk for asymptomatic neuroinvasive syphilis, and according to the Centers for Disease Control and Prevention (CDC) guidelines for management of STDs, he should have a lumbar puncture to rule out neurosyphilis.

Select one of the following:

1. a, b, and c

2. a, c, and d

3. c and d

4. all of the above

4. What is the most appropriate antibiotic regimen for this patient?

a. Ceftriaxone, single intramuscular injection, 1 g

b. Azithromycin, single oral dose, 2 g

c. Benzathine penicillin, intramuscular injection, 2.4 million units (given as a single dose of 1.2 million units in each buttock)

d. Aqueous penicillin G, intravenous injection, 4 million units every 4 to 6 hours for 14 days

e. Benzathine penicillin, 3 intramuscular injections, each administered a week apart, 2.4 million units at each administration (given as a single dose of 1.2 million units in each buttock)

5. If the patient is allergic to penicillin, doxycycline is an option for treatment but has to be given for 14 days and is associated with lower cure rates than parenteral penicillin. True or false?

True False

6. Which statement is correct regarding management of the recent sex partners of this patient with early latent syphilis?

a. Provide empiric treatment to all sexual partners within the past 90 days for early syphilis with benzathine penicillin, even if their RPR test results are negative.

b. Serologically test all sexual partners prior to the past 90 days and treat if serologic test results are positive.

c. Serologically screen all sexual partners within the past 90 days and treat if serologic test results are positive.

Select one of the following:

1. a and b

2. b and c

3. a and c

4. all of the above

7. What is the appropriate posttreatment timeframe for repeating serum VDRL titers in this patient to ensure an effective response to treatment?

a. 6, 12, 18, and 24 months

b. monthly for 1 year

c. annually for life

d. 3, 6, 9, 12, 18, and 24 months

8. Which of the following statements is true regarding the EIA for syphilis?

a. It is a nontreponemal test.

b. It is increasingly used to screen blood donors and as a diagnostic test when syphilis is suspected clinically.

c. Its clinical performance indicates that it is more sensitive and more specific than other serologic assays for the diagnosis of syphilis at all stages.

d. Its major use is to confirm a reactive nontreponemal test (RPR or VDRL).