Syphilis Treatment: Challenges and Alternative Options

Q: Syphilis Treatment: Challenges and Alternative Options

Hello, sir： Based on your description, it is possible that the treatment response is poor. <br>In such cases, it may be necessary to consider performing a lumbar puncture to rule out the possibility of neurosyphilis. <br>The symptoms of syphilis can be quite complex, and sometime

Syphilis index and treatment duration?

Hello Doctor,
In mid-2013, I developed a lesion in my genital area that I initially dismissed as a minor injury from a zipper.
I consulted a urologist, who prescribed a topical medication that I applied for about a week, after which the lesion healed.
I did not follow up on this and delayed treatment.
In October 2014, during a health check-up, I was diagnosed with syphilis.
By the end of December 2014, I went to a major hospital for confirmation and subsequently began treatment.
I received the first course of treatment consisting of three doses of 2.4 million units of benzathine penicillin over three weeks.
Upon returning for follow-up testing in June 2015, my titers had not decreased.
I then started another course of three doses of penicillin.
In December 2015 and January 2016 (I can't recall the exact dates), I returned for blood tests, but my titers remained unchanged, so I continued with the same three-week regimen of penicillin.
Most recently, in mid-June, my titers were still RPR 1:8 and TPHA 1:1280.
I have undergone three treatment courses totaling nine doses of penicillin, yet my titers have not decreased.
The doctor mentioned that early treatment leads to faster decreases in titers, while delayed treatment results in slower decreases.
I am feeling quite exhausted; I have endured the pain of the injections, but my titers remain unchanged.
After this last test, I decided to discontinue penicillin treatment and am now taking one doxycycline pill twice daily for 28 days, with plans for another follow-up at the end of this year.

I would like to ask the following questions:
1.
Why, after three treatment courses and nine injections of 2.4 million units of benzathine penicillin, do my titers still remain at 1:8 and 1:1280 (the same for all three tests)?
2.
Is it possible that my titers will never decrease?
3.
I only have lesions in the genital area, but I do not exhibit signs of secondary or tertiary syphilis; why is that?
4.
If after completing the 28-day doxycycline course my titers still do not decrease, will I need to continue treatment?
5.
What is my current level of infectiousness? Is there a possibility of transmitting the infection to others through safe sexual practices?
6.
Are there any other treatment options available (preferably medications that could lead to a rapid decrease in titers)?
Thank you for your assistance, Doctor.

LIN, 20~29 year old female. Ask Date: 2016/06/30

Dr. Chen Jiansheng reply Urology

Hello, sir: Based on your description, it is possible that the treatment response is poor.
In such cases, it may be necessary to consider performing a lumbar puncture to rule out the possibility of neurosyphilis.
The symptoms of syphilis can be quite complex, and sometimes patients may not exhibit all the signs as described in textbooks.
The most accurate method for diagnosis is still through blood tests.
Generally, syphilis is most contagious within the first two years after infection, particularly during the primary and secondary stages.
After two years, the infectiousness decreases, and it becomes weaker in later stages.
Appropriate penicillin treatment can reduce the patient's infectiousness within 24 to 48 hours.
Regarding your situation, I recommend that you continue to take protective measures.
Sincerely, Chen Jian-sheng, Urology Department, Xinying Hospital.

Reply Date: 2016/06/30

More Info

Syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum, can present significant challenges in treatment, especially when standard therapies do not yield expected results. Your experience with multiple courses of penicillin and the persistent serological titers raises several important considerations regarding the management of syphilis.

1. Why have the titers remained unchanged despite treatment?
The persistence of your RPR (Rapid Plasma Reagin) and TPHA (Treponema pallidum Hemagglutination Assay) titers after multiple treatments can be attributed to several factors. First, it is essential to understand that serological tests for syphilis can remain positive for an extended period, even after successful treatment. In some cases, the RPR may not decrease significantly, especially if treatment was initiated later in the disease course. Additionally, the presence of other underlying conditions or co-infections can complicate the response to treatment.

2. Will the titers ever decrease?
While it is common for titers to remain elevated after treatment, they should ideally decrease over time if the infection is adequately treated. However, some individuals may experience a phenomenon known as "serofast" status, where the RPR remains positive despite successful treatment. This does not necessarily indicate ongoing infection but rather a residual immune response. Continuous monitoring and follow-up testing are crucial to determine the effectiveness of treatment.

3. Why do I only have primary lesions without secondary or tertiary symptoms?
The clinical presentation of syphilis can vary widely among individuals. Some may only exhibit primary lesions, while others may progress to secondary or tertiary stages. The absence of secondary or tertiary symptoms does not imply a lack of infection; rather, it reflects individual variations in immune response and disease progression. Early detection and treatment are critical in preventing the progression of syphilis to later stages.

4. What if the doxycycline treatment does not lead to a decrease in titers?
If the 28-day course of doxycycline does not result in a decrease in titers, it is essential to consult with your healthcare provider for further evaluation. Alternative treatment options may include a different antibiotic regimen or additional courses of penicillin. Continuous monitoring of your serological status will help guide further treatment decisions.

5. What is my current infectious status?
Regarding your infectious status, it is crucial to understand that syphilis is contagious, particularly during the primary and secondary stages. If you have active lesions, there is a risk of transmission to sexual partners. Engaging in safe sex practices, including the use of condoms, is essential to reduce the risk of transmission until you have confirmed treatment success and resolution of the infection.

6. Are there other treatment options available?
While penicillin remains the first-line treatment for syphilis, doxycycline is an alternative for those allergic to penicillin or in specific cases of treatment failure. However, the effectiveness of doxycycline in treating syphilis, particularly in late-stage infections, may not be as well established as penicillin. If you continue to experience challenges with treatment, discussing your concerns with a healthcare provider specializing in infectious diseases may provide additional insights and alternative therapeutic options.

In conclusion, managing syphilis can be complex, particularly when initial treatments do not yield expected results. Continuous communication with your healthcare provider, adherence to treatment regimens, and regular follow-up testing are vital components of effective management. It is essential to remain proactive in your treatment and to seek further evaluation if your condition does not improve.

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