Syphilis is back-we've not forgotten!
We read with interest the excellent article “syphilis: old problem,
new strategy” (BMJ 20th July p153-156 by Lorraine Doherty and colleagues).
There are a number of points they raise that we would like to comment on.
Firstly, they are correct in stating that all genital ulcers are
syphilitic until proved otherwise. However genital ulcers in the UK are
statistically most likely to be herpetic rather than syphilitic. Herpetic
ulcers are charactertistically painful, non-indurated and have a red
margin whereas chancres are usually painless and indurated.
Serological testing, as the authors emphasise, is the mainstay of
diagnosis. However, it is important that the local laboratory uses a
screening test, which is both sensitive and specific in the clinical
scenario. Thus the VDRL or RPR (non treponemal tests) may be negative in
early primary and rarely in secondary syphilis (prozone effect) and are
not appropriate. The most appropriate screening tests are either the EIA
with an IgM component, or the TPPA test (1).
Treatment in the UK has traditionally been with daily injections of
repository penicillin (e.g. procaine penicillin). However, where daily
compliance or poor attendance is thought to be a problem, a once off
injection of benzathine penicillin 2.4 megaunits (MU) or visually
supervised oral azithromycin at the clinic are important alternatives
(2) (3). Oral doxycycline or amoxycillin treatment success depends as
much on patients remembering to take their medication as anything else.
Although treatment failures with one injection of benzathine
penicillin 2.4MU in patients with early syphilis and HIV have been
described (4) (5) (6), the latest CDC guidelines continue to advocate this
one off injection for HIV co-existing with syphilis (2). Evidence for
this may be based on very rare clinical failure in patients who received
benzathine penicillin 2.4 MU rather than benzathine 2.4MU plus high dose
amoxicillin and probenecid in a double blind placebo controlled study of
patients with early syphilis and HIV (7).
Doherty and her colleagues rightly advocate speedy intervention by a
wide range of health professionals in order to control the mini epidemic
of syphilis in the UK. Of vital importance in this regard is easy and
quick access for patients to GU medicine clinics. Unfortunately, this
epidemic has come at a time when access to GUM services, particularly in
London, is deteriorating rather than improving. Many units have changed
from walk – in to appointment only systems in response to unsustainable
increases in activity. Waiting times for appointments are steadily
increasing. In the North Thames region we are now one of only two clinics
providing a daily walk – in service for both male and female patients.
This means that we are frequently overwhelmed by the sheer number of
patients who are travelling from all over London to access care. The very
high patient throughput puts enormous strain on our staff and resources
and does nothing to improve the quality of patients’ experience of
attending a GUM service. This whole situation runs counter to the
government’s current sexual health strategy which aims to improve public
awareness of STIs, reduce stigma and increase access to sexual health
services both hospital – based and in primary care.
There is an urgent need to address access, manpower and funding
issues in GUM services if the current syphilis mini epidemic is to be
dealt with effectively.
Dr David Goldmeier MD FRCP
Dr Linda Greene MRCP
1. Young H. Guidelines for serological testing for syphilis. Sex.
Trans.Inf. 2000; 76:403-405.
2. CDC Guidelines. May 2002 available at www.cdc.gov/std/treatment/2-
3. Gruber F, Kastelan M, Cabrijan L, Simonic E, Brajac I. Treatment
of early syphilis with azithromycin. J. of Chemotherapy. 2000; 12:240-3.
4. Johns D R, Tierney M, Felsenstein D. Alteration in the national
history of neurosyphilis by concurrent infection with the human
immunodeficiency virus. N. Engl.J.Med. 1987; 316:1569-72.
5. Berry CD, Hooton TM, Collier AC, Lukehart SA. Neurological relapse
after benzathine penicillin therapy for secondary syphilis in a patient
with HIV infection. N.Engl.J.Med: 1987; 316:1587-9.
6. Musher DM, Hammill RJ, Baughn RE. Effect of human immunodeficiency
virus (HIV) infection on the course of syphilis and its response to
treatment. Ann.Intern.Med. 1990; 113:872-81.
7. Rolfs RT, Joesoef MR, Hendershot EF et al. A randomised trial of
enhanced therapy for early syphilis in patients with and without Human
Immunodeficiency virus infection. N.Engl.J.Med 1997; 337:307-314.
Competing interests: No competing interests