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June 2011
Patient Care and Science
EIN Update: Syphilitic Scleritis and Screening Dilemmas for Syphilis

The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN’s sponsor), or the Centers for Disease Control and Prevention (CDC), which funds EIN. The reader assumes all risks in using this information.

EIN members recently discussed ocular manifestations of syphilis and issues raised by new screening tests.

A member in Texas described a 60-year-old woman with six months of scleritis who was positive for syphilis by Treponema pallidum particle agglutination assay (TPPA) but negative by the rapid plasma reagin (RPR) test. The patient related a history of being treated in the 1970s for a sexually transmitted disease (STD) acquired from her husband, but she had no records and did not recall what the treatment was other than an injection. The woman’s current cerebrospinal fluid (CSF) exam was negative.

“Should she be treated for neurosyphilis or just for late latent syphilis?” the member asked.

The member noted that the Centers for Disease Control and Prevention (CDC), in its  2010 STD treatment guidelines, advises “syphilitic uveitis or other ocular manifestations . . . should be managed according to the treatment recommendations for neurosyphilis. Patients who have neurosyphilis or syphilitic eye disease (e.g., uveitis, neuroretinitis, and optic neuritis) should be treated with the recommended regimens for neurosyphilis.”

Given this recommendation, “Does scleritis with a positive TPPA equate to uveitis, neuroretinitis, or optic neuritis?” the member asked.

It is rare to have active syphilis, including late syphilis, with a negative nontreponemal test, such as RPR or a venereal disease research laboratory (VDRL) test, an EIN member in Washington state responded. “I’m not sufficiently attuned to ‘scleritis’ in general or in association with syphilis, and have not heard it described as a manifestation of syphilis,” the member continued. Uveitis is usually associated with early syphilis, not tertiary — and usually with a high RPR/VDRL titer.

“My bet is that the patient’s scleritis and reactive TPPA are unrelated,” wrote the member, who suggested treating the patient “with benzathine penicillin as for late latent syphilis. If the scleritis resolves, it would tend to support syphilis as a cause, and nonresponse probably would rule it out.”

A respondent in Texas noted similar issues. The new automated screens that have replaced RPR have raised questions, “as we often have patients with symptoms that fit, often barely, within the very wide range of clinical manifestations of syphilis, but have a negative RPR and positive ‘new screen.’  I have yet to see a convincing case of neurosyphilis (with diagnostic CSF findings) in this group, including those with scleritis or uveitis, but have treated several at the insistence of ophthalmology.”

“My inclination, with normal CSF (or in those where there is no reason to check), is to treat these as latent,” the member wrote.

Given the possibility that the scleritis is due to syphilis, an EIN member in Oregon favored re-treatment for latent syphilis as well. “If she has no evidence of intraocular inflammation and a negative CSF examination, then I would not classify her as neurosyphilis.”

The Washington state member also noted the challenges raised by newer screening tests for syphilis, which have complicated long-established diagnostic and treatment practice.

“The past few years have seen a scramble by CDC and other public health agencies to figure out the impacts and give guidance on use,” noted the member, who referenced a “superb review” published in the Sept. 15, 2010, issue of Clinical Infectious Diseases. The results of an EIN survey, conducted in late 2008 and published in Clinical Infectious Diseases, also address some of the relevant screening issues.

E-mail the Emerging Infections Network.

The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) with funding from the Centers for Disease Control and Prevention (CDC), EIN tracks emerging infectious diseases and keeps the public health community up to date with new disease trends, difficult cases, and other issues affecting members’ clinical practices. The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. Click here for more information or to join EIN.
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