Syphilis: The Daily PANCE Blueprint

The answer is A, Benzathine penicillin

Benzathine penicillin is the mainstay of treatment for all stages of syphilis.

Pearls

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum and has increased in incidence over the last 10 years; it is associated with risk-taking behavior such as drug use. The disease has three phases, with an incubation period of about 3 weeks:

• Primary syphilis (localized): presents as a painless chancre in the genital or groin region persisting 3 to 6 weeks.
• Secondary syphilis (disseminated): presents as an erythematous maculopapular rash involving the palms and soles or a condyloma lata which is similar to the lesions of primary syphilis in its infectivity but differs in appearance.
• Tertiary syphilis (systemic): Affects about 30% and is a representation of widespread systemic involvement and can present with major vessel changes, such as in the aorta, permanent CNS changes (neurosyphilis), or even benign mucosal growths called gummas.

Congenital syphilis: 

• Early (First 2 years): Stillborn, maculopapular rash on palms and soles, damage to liver and spleen, optic neuritis, snuffles
• Late (>2 years): Hutchinson teeth (notches on teeth). Saddle-nose deformity, ToRCH syndrome.

Diagnosis

• Identify spirochetes in chancres using dark field microscopy
• Confirm with serological tests for antibodies against T. pallidum:
• Non-Treponemal tests (detect anti-cardiolipin antibodies): RPR, VDRL
• Treponemal tests (detect antibodies that target T. pallidum commonly used after +VDRL or RPR): TPPA, FTA-ABS 
• Lumbar puncture should be performed in patients suspected of having neurosyphilis with no contraindication
• Some conditions may cause a false positive test, including, IV drug use, Lyme disease, Certain types of pneumonia, Malaria, Pregnancy, Systemic lupus erythematosus, and some other autoimmune disorders, Tuberculosis (TB)

Treatment

The treatment for syphilis is penicillin G (IM/IV)

• IM for primary and secondary disease
• IV for congenital and late disease
• Doxycycline or tetracycline (PO); ceftriaxone (IM, IV) if penicillin allergy

Watch for Jarisch Herxheimer reaction – spirochetes die releasing lots of antigens resulting in immune system reaction with fevers, sweating, muscle and joint pain lasting hours to days