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Syphilis Detection Test 

  • Author: Roman Bronfenbrener, MD; Chief Editor: Eric B Staros, MD  more...
 
Updated: Dec 17, 2014
 

Reference Range

Syphilis detection tests are serologic tests used to screen for and confirm infection with Treponema pallidum.

Electron micrograph of Treponema pallidum.
Electron micrograph of Treponema pallidum.

The reference range for syphilis detection tests reflects an absence of treponemal exposure, as follows:

  • Venereal Disease Research Laboratory (VDRL) test: Nonreactive
  • Rapid plasma reagin (RPR): Nonreactive
  • Fluorescent treponemal antibody absorption test (FTA-ABS): Nonreactive
  • T pallidum particle agglutination (TP-PA): Nonreactive
  • Enzyme immunoassay (EIA): Nonreactive
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Interpretation

The results of syphilis detection tests need to be placed in the context of the patient’s clinical presentation; primary syphilis may not yet show seroconversion, and levels in patients with latent or tertiary syphilis may decline to the point of nonreactivity.

Table 1. Sensitivity of Syphilis Tests (Open Table in a new window)

  Primary Syphilis Secondary Syphilis Latent Syphilis Tertiary Syphilis
RPR/VDRL 78%-86% 100% 95%-100% 71%-73%
FTA-ABS 84% 100% 100% 96%
TP-PA 89% 100% 100% Data not yet available
EIA 82%-100% 100% 98-100% Data not yet available

The specificity rates of syphilis tests are as follows:

  • RPR/VDRL: 85%-99%
  • FTA-ABS/TP-PA/EIA: 96%

All positive RPR and VDRL test results should prompt follow-up with FTA-ABS or TP-PA. Biologic false-positive results are defined as a positive RPR/VDRL result with a negative FTA-ABS/TP-PA result and are due to reactivity of autoantibodies to the cardiolipin-lecithin-cholesterol reagent present in the nontreponemal tests. Generally, these present with a low titer (≤1:8) in patients with the following:[2]

  • Autoimmune disease (systemic lupus erythematosus, antiphospholipid antibody syndrome)
  • Intravenous drug use
  • HIV infection
  • Treponemal infection (yaws, pinta, bejel)
  • Pregnancy
  • Advanced age (10% in patients >70 years)
  • Malignancy
  • Tuberculosis
  • Malaria
  • Viral disease (hepatitis, mononucleosis)
  • Hansen disease

Neurosyphilis

Lumbar puncture VDRL to detect CNS involvement should be performed in the following:[2]

Patients with positive serum serology findings and evidence of neurologic or ophthalmologic involvement

Patients with HIV infection who also have syphilis of unknown duration or more than one year duration

Response to treatment

Nontreponemal (RPR/VDRL) titers can be used to monitor treatment response. Successful treatment is associated with a 4-fold or two-tube decline in titer (ie, from 1:32 to 1:8) 6 months after therapy for primary or secondary syphilis and 1 year after therapy for latent syphilis. RPR and VDRL titers are not interchangeable or convertible, so it is important to use consistent testing with a single method to monitor disease activity. The treponemal (FTA-ABS/TP-PA) tests remain positive for the life of the patient regardless of therapy, and titers are not reported.[11, 12]

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Collection and Panels

Specimen: 5-10 mL of venous blood collected for this test

Collection method: Routine venipuncture; no preparation required in advance of the blood draw

Specimen container: Red-top Vacutainer tube (see image below)

Rejection: Hemolyzed, lipemic, and grossly contaminated samples invalidate testing

Storage: Sample should be refrigerated

Red-top Vacutainer tube. Red-top Vacutainer tube.
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Background

Syphilis detection tests are serologic tests used to screen for and confirm infection with T pallidum. These tests have largely replaced direct visualization of spirochetes owing to greater ease of testing, less reliance on observer experience, and less-expensive equipment. The tests are categorized into two serologies: nontreponemal tests and the treponemal tests.

Description

Nontreponemal tests include the Venereal Disease Research Laboratory (VDRL) test and the rapid plasma reagin (RPR) test. They were the earliest developed, with the VDRL in use since its development in 1906. These tests are used to detect immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies against a cardiolipin-lecithin-cholesterol antigen, which are formed indirectly during infection with T pallidum. Because these antibodies are not specific for T pallidum, false-positive results on nontreponemal tests are frequently encountered in numerous physiologic and pathologic conditions (see Interpretation). Positive nontreponemal test findings should be confirmed with treponemal serology. Apart from their use in screening and diagnosis, nontreponemal antibody titers are used to measure disease activity, as higher titers are positively correlated with bacterial load.

Treponemal tests include fluorescent treponemal antibody absorption test (FTA-ABS), T pallidum particle agglutination test (TP-PA), chemiluminescence immunoassay (CIA), and enzyme immunoassay (EIA). These are used to test for the presence of antibody to specific components of treponemal organisms and therefore have lower false-positive rates. This higher specificity makes them ideal as confirmatory tests after a less-expensive nontreponemal test shows reactivity. However, because subspecies of T pallidum cause ailments distinct from syphilis, these tests will show seropositivity in patients with yaws, pinta, and endemic/nonvenereal syphilis (bejel).[1, 2, 3, 4, 5, 6, 7]

EIA and CIA are treponemal tests used by some laboratories in a testing method referred to as reverse testing. Unlike traditional testing, which uses a nontreponemal test as the initial screening, in reverse testing, the EIA/CIA test is performed first and, if positive, reflex tested with a quantitative RPR/VDRL. Discordant results after reflex testing (ie, positive CIA/EIA findings with a nonreactive RPR/VDRL result) require further testing with TP-PA. Because of confusion about discordant results, the CDC still recommends traditional testing, although EIA/CIA is gaining popularity because of easier automation, and it may be the method of choice in the future.[8]

Considerations

In patients with HIV infection, serology is an effective screening method for concomitant syphilis infection. Generally, higher serum titers are seen in patients with HIV, however, unpredictable responses including delayed seroconversion and false negatives have rarely been reported. In patients with negative serology but strong clinical suspicion, dark field microscopy of lesions can be used to establish a diagnosis.[9, 10]

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Contributor Information and Disclosures
Author

Roman Bronfenbrener, MD Resident Physician, Department of Dermatology, State University of New York, Stony Brook University School of Medicine

Roman Bronfenbrener, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Chief Editor

Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of Clinical Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital

Eric B Staros, MD is a member of the following medical societies: American Medical Association, American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology

Disclosure: Nothing to disclose.

Acknowledgements

Judy Lin, MD

Disclosure: Nothing to disclose.

References
  1. Diagnostic Tests. BestPractice. Web. BMJ. 22 Mar 2012. [Full Text].

  2. Fauci, Anthony S. "162 / Syphilis." Harrison's Principles of Internal Medicine. New York: McGraw-Hill Medical; 2008.

  3. U.S. Preventive Services Task Force. Screening for Syphilis Infection: Recommendation Statement. July 2004. [Full Text].

  4. Castro R, Lopes A, da Luz Martins Pereira F. Evaluation of an Immunochromatographic Point-of-Care Test for the Simultaneous Detection of Nontreponemal and Treponemal Antibodies in Patients With Syphilis. Sex Transm Dis. 2014 Aug. 41(8):467-9. [Medline].

  5. Kuo M, Money DM, Alvarez M, Buxton JA, Krajden M, Lester RT, et al. Test Uptake and Case Detection of Syphilis, HIV, and Hepatitis C Among Women Undergoing Prenatal Screening in British Columbia, 2007 to 2011. J Obstet Gynaecol Can. 2014 Jun. 36(6):482-90. [Medline].

  6. Zhiyan L, Meiling W, Ping L, Jinhua D, Zhenlin Y, Zhenru F. Consistency Between Treponema pallidum Particle Agglutination Assay and Architect Chemiluminescent Microparticle Immunoassay and Characterization of Inconsistent Samples. J Clin Lab Anal. 2014 May 19. [Medline].

  7. Jost H, Castro A, Cox D, Fakile Y, Kikkert S, Tun Y, et al. A comparison of the analytical level of agreement of nine treponemal assays for syphilis and possible implications for screening algorithms. BMJ Open. 2013 Sep 19. 3(9):e003347. [Medline]. [Full Text].

  8. Egglestone, SI. Serological Diagnosis of Syphilis." UK Health Protection Agency. Communicable Disease in Public Health, Web. [Full Text].

  9. Radolf, JD, G. Bolan, JM Chow, et al. Discordant Results from Reverse Sequence Syphilis Screening --- Five Laboratories, United States, 2006--2010." Centers for Disease Control and Prevention. 11 Feb. 2011. [Full Text].

  10. Musher DM, Hamill RJ, Baughn RE. Effect of human immunodeficiency virus (HIV) infection on the course of syphilis and on the response to treatment. Ann Intern Med. 1990 Dec 1. 113(11):872-81. [Medline].

  11. Sexually transmitted diseases treatment guidelines 2002. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 May. 51(RR-6):1-78.

  12. Romanowski B, Sutherland R, Fick GH, Mooney D, Love EJ. Serologic response to treatment of infectious syphilis. Ann Intern Med. 1991 Jun 15. 114(12):1005-9. [Medline].

 
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Electron micrograph of Treponema pallidum.
Red-top Vacutainer tube.
Table 1. Sensitivity of Syphilis Tests
  Primary Syphilis Secondary Syphilis Latent Syphilis Tertiary Syphilis
RPR/VDRL 78%-86% 100% 95%-100% 71%-73%
FTA-ABS 84% 100% 100% 96%
TP-PA 89% 100% 100% Data not yet available
EIA 82%-100% 100% 98-100% Data not yet available
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