Syphilis is a
sexually transmitted infection which is systemic from the outset and has increased in incidence worldwide over the last decade. There has been concern as to whether or not
co-infection with HIV can modify the clinical presentation of
syphilis and, as a genital
ulcer disease, it can facilitate the transmission of
HIV infection. Diagnosis is based on the microscopic identification of the causative treponeme and serological testing. Recommendations for the treatment of
syphilis have been based on expert opinion, case series, some clinical trials and 50 years of clinical experience.
Penicillin, given intramuscularly, is the mainstay of treatment and the favoured preparations for early infectious
syphilis are
benzathine penicillin as a single injection or a course of daily
procaine penicillin injections for 10 to 14 days. The
duration of treatment is longer for
late syphilis. There has been concern that
benzathine penicillin may not prevent the development of
neurosyphilis but that is a rare outcome with this
therapy. The main alternative to
penicillin is
doxycycline, but the place of
azithromycin and
ceftriaxone is yet to be established. It is not necessary to carry out examination of the cerebrospinal fluid in patients with early infectious
syphilis but it should be performed in those with neurological or ocular signs, psychiatric signs or symptoms, when there is evidence of treatment failure and in those who are co-infected with HIV. Follow-up is an essential part of management and should be particularly assiduous, for at least 24 months, in those co-infected with HIV. Partner notification should be mandatory to try to contain the spread of
infection.