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In order to provide candidates with a valid and reliable examination, NCRA has started to pretest items for the RPR, RMR, and RDR examinations. Std screening nearby South Carolina. Pretesting ensures that all items on an examination are items with good statistics and no brand-new, untried items will appear on any examination. The RPR and RDR examinations will include items for pretesting. This means that the examinations will now have 115 items instead of 100 items. These items will not be scored, so the exams are still based off of 100 points. Candidates will not know which items are pretest items. Also, with the addition of the items, the RPR will now be 105 minutes instead of 90 minutes to allow candidates sufficient time to finish the examination.

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The diagnosis and treatment of syphilis can present difficult dilemmas. Serologic tests can be negative if they are performed at the stage when lesions are present, and the VDRL test can be negative in patients with late syphilis. Cerebrospinal fluid examination is not required in patients with primary or secondary disease and no neurologic signs or symptoms, but it may be warranted in patients with late latent syphilis or in whom the duration of infection is unknown. Patients with penicillin allergy can be treated with alternative regimens if they have primary or secondary syphilis. Penicillin is the only effective drug for neurosyphilis; oral desensitization should be accomplished before treatment of penicillin-allergic patients. Other dilemmas may be encountered in the treatment of patients who have concurrent human immunodeficiency virus infection.

The symptoms of primary syphilis become evident about three weeks after infection, although the onset of symptoms may range from three to 90 days. 2 One or more characteristic chancres erupt at the site of inoculation. Syphilitic chancres are classically described as painless, indurated, clean-based ulcers, unlike chancroid ulcers, which are deep, undermined and purulent, and herpetic ulcers, which are generally multiple, shallow and tender. 3 Nonulcerative lesions occasionally occur. Although regional lymphadenopathy is common in primary syphilis, it is not an essential component in the diagnosis. Without treatment, the chancre usually resolves in three to six weeks.

If untreated, primary syphilis progresses to secondary syphilis between two weeks and two months after the appearance of the chancre. While secondary syphilis has many manifestations, a rash is the most common. Virtually any kind of rash, except a vesicular one, can occur in secondary syphilis. A maculopapular rash on the palms and soles is especially suggestive of syphilis. Ulcers and flattened eroded lesions on the mucous membranes (which are often referred to as mucous patches”) can occur in the mouth or throat. Fever, pharyngitis, arthralgias or generalized lymphadenopathy develop in most patients with secondary syphilis.

Systemic involvement can occur in secondary syphilis and anytime thereafter. Syphilitic meningitis is usually a slowly developing, mild to moderate meningitis characterized by stiffness of the neck, headache, nausea and vomiting, unlike the rapidly evolving febrile presentation seen in bacterial meningitis. 4 , 5 Cranial nerve abnormalities, especially of the seventh and eighth nerves, are common in syphilitic meningitis. Std Screening closest to South Carolina. Other types of systemic involvement include hepatitis, uveitis and nephritis.

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Tertiary syphilis develops in 8 to 40 percent of untreated patients. Std screening in South Carolina. 7 It most commonly presents as neurosyphilis, which can be asymptomatic or can produce a variety of clinical syndromes, most classically tabes dorsalis and general paresis. Because differentiation of these syndromes from nonsyphilitic causes of neurologic disease can be difficult, particularly in the demented patient, familiarity with the well-described clinical syndromes is essential. Tabes dorsalis, with its characteristic wide-based steppage” gait, signifies destruction of the dorsal roots of the spinal column. Lightning pains of the extremities, decreased peripheral reflexes and urinary and fecal incontinence can also occur. General paresis is chiefly manifested by chronic dementia but can be accompanied by other neurologic signs as well.

Initial screening for syphilis is performed with one of the nontreponemal antibody tests, the VDRL test or the reactive plasma reagin (RPR) test. These tests are quite sensitive yet not very specific for syphilis. The VDRL and RPR, respectively, are reactive in 78 percent and 86 percent of patients with primary syphilis. 8 They become positive within approximately four to six weeks after infection or one to three weeks after the appearance of the primary lesion. Thus, these tests can be negative in early syphilis, when patients have lesions. Conversely, in late syphilis, about one fourth of untreated patients have negative VDRL results. 8 Therefore, the nontreponemal tests cannot be relied on for diagnosis when the disease is in its very early or late stage.

The specific treponemal tests are the micro-hemagglutination assay for Treponema pallidum (MHA-TP) and the fluorescent treponemal antibody absorption (FTA-ABS) test. The MHA-TP is positive in 76 percent of patients with primary syphilis, and the FTA-ABS is positive in 84 percent. 8 Compared with nontreponemal tests, treponemal tests may become positive earlier in the course of infection. Std Screening in South Carolina. 5 Titers of the treponemal tests do not correlate with disease activity and cannot be used to follow the patient's response to treatment.

A final method of detection of T. pallidum is direct visualization of the organism by using one of several techniques. The presence of characteristic organisms in a specimen obtained from a typical lesion of very early syphilis is diagnostic, even in the absence of positive serologic tests. Dark-field microscopy of material from a genital lesion demonstrates corkscrew-like organisms moving with a spiraling motion. Oral and anal lesions cannot be used as sources for specimens because of the presence of nonpathogenic treponemes. An alternative to this technique is immunofluorescence or immunoperoxidase staining by means of specific treponemal antibodies. 9 Because this technique is immunologic, it can distinguish pathogenic from nonpathogenic treponemes with a specificity approaching 100 percent. However, interpretation of these tests requires considerable expertise. Repeated attempts at detection are necessary before the tests can be declared truly negative.

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A common dilemma in diagnostic testing for syphilis is the role of a cerebrospinal fluid (CSF) evaluation in diagnosing neurosyphilis. 10 In patients with primary or secondary syphilis but no neurologic signs or symptoms, CSF evaluation is not required. Such patients are not at significant risk of neurologic complications or other recurrences when they receive the standard therapy for early syphilis. Conversely, in patients with neurologic symptoms or signs potentially attributable to syphilis, CSF examination is generally required.

The question of whether to evaluate CSF in patients with latent syphilis is a frequent clinical problem. Patients who are certain they were infected within the preceding year are considered to have early latent syphilis and generally do not require a CSF evaluation. Std Screening Near Me South Dakota. However, patients often cannot identify the time of infection because the lesions of primary syphilis are painless and often remain unnoticed. Similarly, the rash of secondary syphilis may not be recognized as a sign of secondary syphilis. Both the lesion and rash resolve without treatment.

Other indications for lumbar puncture in patients with latent disease are listed in Table 3 6 The necessity of performing a lumbar puncture in asymptomatic immunocompetent patients with late latent syphilis or syphilis of uncertain duration remains a clinical dilemma. Asymptomatic neurosyphilis, defined as CSF cellular and protein abnormalities, may be found in 10 to 30 percent of patients with latent syphilis. 5 Although relatively uncommon, this state can progress to symptomatic disease and irreversible neurologic damage. Because there is no absolute indication for lumbar puncture under these circumstances, patients should be advised of the risk of disease progression and should participate in the decision-making process. 6

When CSF evaluation is performed, it should include determination of protein and glucose levels, cell count and VDRL. The RPR is not valid in a CSF evaluation because of a high false-positive rate. The CSF-VDRL is specific but not sensitive, so false-negative results can occur. It should not be used to exclude neurosyphilis. 11 Sometimes the only indication of neurosyphilis is an elevated CSF leukocyte count (more than 5 white blood cells per mm3) or a CSF protein measurement greater than 40 mg per dL (40 mg per L). 12 Low CSF glucose levels are also consistent with neurosyphilis.

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Approximately 10 percent of adults report a history of allergy to penicillin. 1 Because penicillin is the best treatment for syphilis, the allergy history should be carefully assessed to ensure that penicillin therapy is administered whenever possible. Persons with definite penicillin allergy and primary or secondary syphilis can be treated with an alternative regimen of doxycycline, in a dosage of 100 mg orally twice daily for 10 days. This regimen is generally better tolerated than an equivalent tetracycline regimen. Erythromycin, in a dosage of 500 mg orally four times daily for two weeks, is a second alternative, although it is not as effective as doxycycline. Evidence for the effectiveness of ceftriaxone (Rocephin) is limited, 14 , 15 but a regimen of 1 g daily, given intramuscularly for eight to 10 days, may maintain adequate treponemacidal levels. 6 Careful monitoring of the serologic response is necessary to ensure eradication of the organism whenever an alternative regimen is used. Std screening in South Carolina.

Penicillin is the only antibiotic with proven efficacy in neurosyphilis and syphilis in pregnancy. Allergic patients should undergo oral desensitization followed by treatment with penicillin. Consultation with an expert is advised when serious complications are a concern. An alternative to desensitization in all patients who report a history of penicillin allergy is skin testing. Some authorities assert that penicillin is also the only appropriate treatment for patients with HIV infection and syphilis, and that penicillin-allergic patients with both diseases should be desensitized and treated with penicillin. In the absence of pregnancy or HIV infection, however, patients with latent syphilis and penicillin allergy should be treated with doxycycline or tetracycline. The duration of therapy is two weeks for early latent syphilis and four weeks for syphilis of unknown duration or late latent syphilis. 6

All of the signs and symptoms of primary or secondary syphilis usually resolve with or without treatment. Following proper treatment, patients with primary, secondary and early latent disease have less than a 10 percent risk of progression to late complications. 16 Predicting the response to treatment of neurosyphilis is somewhat more complicated. Symptoms of syphilitic meningitis and, to a lesser extent, meningovascular syphilis usually resolve with treatment. Std screening nearby South Carolina. However, symptoms of tabes dorsalis or general paresis are unlikely to abate. The purpose of treatment in such cases is to arrest further disease progression.

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Laboratory follow-up after treatment of primary or secondary syphilis consists of evaluating the VDRL or RPR titers at six and 12 months after antibiotic therapy, or more frequently if compliance with follow-up is uncertain. 6 No studies have established the absolute laboratory criteria for successful therapy, but a large epidemiologic study indicates that patients who have primary or secondary syphilis should show a fourfold (two tube) decrease in the titers by six months, and those with early latent syphilis should have a fourfold decrease by one year. 18

Although current treatment recommendations from the Centers for Disease Control and Prevention (CDC) are considered adequate, 22 careful follow-up with serial serologic tests, clinical assessment and CSF examination (in the case of neurosyphilis) is necessary. There are reports of HIV-infected patients who have persistent or recurrent syphilis despite appropriate antisyphilitic therapy. 21 , 23 In addition, the serologic response to therapy is often less predictable in HIV-positive patients than in HIV-negative patients, particularly those with primary or secondary syphilis. This altered serologic response, however, does not necessarily indicate a poorer clinical response.

Penicillin is the only acceptable treatment regimen in the pregnant patient: it treats the infected fetus as well as the mother. The Jarisch-Herxheimer reaction, although not more common in pregnancy, can cause premature uterine contractions and fetal distress. Std Screening Near Me Rhode Island. 24 Because the consequences of congenital syphilis, both early (stillbirth, prematurity, anemia, thrombocytopenia) 25 and late (deafness, mental retardation, seizures, bony deformities), 26 are severe, these prenatal risks should not alter the decision to treat the patient, but careful observation is necessary.

NINA R. BIRNBAUM, M.D., is assistant clinical professor in the Department of Family and Community Medicine at the University of California-San Francisco School of Medicine and physician consultant for the National HIV Telephone Consultation Service (Warmline) at the University of California-San Francisco and the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPline). After graduating from Columbia University College of Physicians and Surgeons, New York City, Dr. Birnbaum completed a residency at the UCSF Family Practice Residency Program at San Francisco General Hospital.... Std screening in South Carolina.