eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Syphilis: Follow-up

Author: Muhammad Waseem, MD, Associate Professor of Emergency Medicine in Clinical Pediatrics, Weill Medical College of Cornell University; Consulting Staff, Department of Pediatrics, Bronx Lebanon Hospital; Consulting Staff, Department of Emergency Medicine, Lincoln Medical and Mental Health Center
Coauthor(s): Muhammad Aslam, MD, Instructor in Pediatrics, Harvard Medical School; Staff Physician, Department of Medicine/ Division of Newborn Medicine, Children's Hospital Boston
Contributor Information and Disclosures

Updated: Jul 28, 2009

Follow-up

Further Inpatient Care

• Standard precautions are recommended for all patients with primary and secondary syphilis because these lesions are moist and potentially infectious.

Further Outpatient Care

• Follow up congenital syphilis with evaluation at age 1 month, 2 months, 4 months, 6 months, and 12 months. Obtain nontreponemal titers at age 3 months, 6 months, and 12 months after conclusion of treatment. Nontreponemal antibody titers should decline by age 3 months and should be nonreactive by age 6 months. Consider retreatment for patients with persistently stable titers, including low titers.
• Infants who are treated for congenital neurosyphilis should undergo repeat clinical evaluation and cerebrospinal fluid (CSF) examination at 6-month intervals until their CSF examination result is normal. A positive CSF Venereal Disease Research Laboratory (VDRL) result at age 6 months is an indication for retreatment.
• Follow up early acquired syphilis with a quantitative nontreponemal test at 3-month, 6-month, and 12-month intervals after conclusion of treatment. Patients with syphilis for more than one year also should undergo serologic testing 24 months after treatment. Pregnant patients who have received treatment should have quantitative serologic testing monthly for the remainder of their pregnancy.¹¹

Transfer

• Transfer to another facility is appropriate if the required specialists or treatments are unavailable locally.

Deterrence/Prevention

• Although rates of early syphilis are declining, maintaining a high index of suspicion about at-risk patients is important. Indications for syphilis screening include the following:
• Exposure to a known case of infectious syphilis
• All women at first prenatal visit and high-risk women again at 28 weeks' gestation (Forty six of the 50 states [90%] and the District of Columbia have laws regarding antenatal syphilis screening during pregnancy and at delivery.)
• All women that deliver a stillborn infant
• All newborns older than 22 weeks' gestation whose mothers were not screened
• Anyone diagnosed with a sexually transmitted disease (STD) or anyone presenting for STD evaluation
• Any person who tests positive for HIV
• Anyone engaging in high-risk behaviors (eg, drug use, prostitution, unprotected sex)
• Drainage and secretion precautions are necessary for all patients who have suspected or proven syphilis until therapy has been administered for at least 24 hours.
• Trace and contact all sexual partners of infected patients
• All persons (including health care providers) who have had close, unprotected contact with early congenital syphilis before identification of the disease or during the first 24 hours of therapy should be examined clinically for the presence of lesions 2-3 weeks after contact. Serologic testing should be performed and repeated 3 months after contact or earlier if symptoms occur. Consider immediate treatment if the degree of exposure may have been significant.
• Many people who are sexually assaulted do not comply with recommended follow-up, so consider empiric therapy for these patients.

Complications

• Virtually any organ in the body can be involved.
• Fatal osteomyelitis of sternal bone caused by syphilis infection has been reported in a homosexual man.¹² T pallidum DNA polymerase chain reaction (PCR) was used for the first time to diagnose this condition with very promising results.

Prognosis

• With adequate and timely treatment, prognosis is excellent.
• Patients with HIV infection have a high rate of failed serologic response to syphilis treatment. Most of them show no response or inadequate response after being treated for syphilis.

Patient Education

• Until a practical and effective vaccine is developed, syphilis prevention depends on abstinence, the use of condoms, and detection and identification of infectious cases. Education about STDs, treatment of sexual contacts, and the reporting of each case to local public health authorities are essential.
• For excellent patient education resources, visit eMedicine's Sexually Transmitted Diseases Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Sexually Transmitted Diseases, Syphilis, Birth Control Overview, and Birth Control FAQs.

Miscellaneous

Medicolegal Pitfalls

• Routine prenatal screening for syphilis remains the most important factor in identifying infants at risk of developing congenital syphilis. Screening is legally required at the beginning of prenatal care in all states.
• No newborn should leave the hospital without determination of maternal serologic status at least once during pregnancy.
• Testing of mother's serum is preferred to testing cord blood or the infant's serum because the titers frequently are lower in the infant and may be nonreactive if the mother was infected late in pregnancy. 
• Test for syphilis any woman who delivers a stillborn infant after 20 weeks' gestation.
• Screen women at high risk for syphilis more frequently because they may have repeat infections during pregnancy or become reinfected late in pregnancy.
• Laboratory evaluation of sexually abused children should include serologic testing for syphilis if the assailant has a history of syphilis or other sexually transmitted disease (STD). A suspicion of child sexual abuse mandates filing a report with child protective services or law enforcement agencies.
• Syphilitic stillbirth is considered fetal death after 20 weeks' gestation or when a fetus weighs more than 500 g and the mother had untreated or inadequately treated syphilis at delivery. Report these cases as congenital syphilis.
• Diseases that cause genital ulcers, including syphilis, may provide vascular portals of entry for HIV. Evaluate any patient with known or suspected syphilis for the possibility of neurosyphilis, which is known to have an increased incidence among individuals with HIV infection.
• Consider STD prophylaxis for rape victims.

Special Concerns

• Syphilis in pregnancy
  • Treponemes appear able to cross the placenta at any time during pregnancy, thereby infecting the fetus. Syphilis can cause preterm delivery, stillbirth, congenital infection, or neonatal death, depending on the stage of maternal infection and the duration of fetal infection prior to delivery. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics in their joint publication, Guidelines for Perinatal Care, recommend screening for syphilis at the first prenatal visit for all women and at 32-36 weeks’ gestation for women who are at risk.¹³ In the 2003 Red Book: Report of the Committee on Infectious Diseases , the American Academy of Pediatrics recommends screening early in pregnancy and preferably again at delivery.^14,11
  • All pregnant women should have a nontreponemal serologic test for syphilis at the first prenatal visit. Perform a second test during the third trimester, especially in those at increased risk of contracting disease. Seropositivity with a nontreponemal test requires complete evaluation, including quantitative nontreponemal serology and confirmatory treponemal serology.
  • CDC policy states that no newborn should leave a hospital without documentation of the mother's serologic status at least once during the pregnancy. Serologic testing should also be performed at delivery in communities and populations at risk of acquiring congenital syphilis.
  • Penicillin is the only recommended therapy for syphilis in pregnancy. If the patient has a penicillin allergy that is confirmed by the demonstration of an immediate wheal-and-flare response to skin testing with penicilloyl-polylysine or penicillin G minor determinant mixture, desensitization and penicillin treatment should be performed in a hospital, following the 1993 STD guidelines issued by CDC.
  • Warn patients about the risk of a Jarisch-Herxheimer reaction; this reaction may be associated with mild premature contractions but rarely results in premature delivery.
• Syphilis in persons with HIV
  • Concomitant HIV and syphilis is common.
  • Serologic tests for syphilis may be modified by the presence of HIV, usually resulting in extremely high titers and failure to decrease in response to adequate treatment.
  • A serologic response may fail to develop.
  • Treatment of co-infected individuals may require high-dose or prolonged therapy.
  • Some authorities, persuaded by reports of the persistence of T pallidum in the cerebrospinal fluid (CSF) of persons infected by HIV after standard penicillin benzathine therapy for early syphilis, now recommend CSF examination of all co-infected patients for neurosyphilis, regardless of the clinical stage of syphilis. These authorities treat for neurosyphilis when no CSF examination is performed or when examination reveals CSF abnormalities.
  • Serologic testing after treatment is important for all patients with syphilis, particularly those co-infected with HIV.
• Persistent infection
  • The question of persistent infection despite adequate therapy has been controversial. Sequestration of spirochetes has been reported in such sites as the anterior chamber of the eye, the CNS, and the labyrinth of the inner ear. CSF parameters are expected to normalize within 2 years. Failure to normalize may warrant retreatment.
  • Anyone with neurologic, optic, or otic abnormalities who has or has a history of syphilis (current or untreated) should be considered for CSF examination and should be treated for neurosyphilis.

• Search for CME/CE on This Topic »

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