Trascrizione completa di Syphilis: The Great Masquerader

article or are going to read the article, the 37 00:01:54,496 --> 00:01:58,606 best summary would be everything you see is syphilis and everyone should just be 38 00:01:58,606 --> 00:02:00,466 drinking penicillin on a daily basis. 39 00:02:01,266 --> 00:02:04,746 T.R. Eckler: I feel especially qualified to celebrate and appreciate 40 00:02:04,746 --> 00:02:08,796 this article because Dr. Chen, he was my chief when I was an intern in 41 00:02:08,896 --> 00:02:09,836 Sam: No way. 42 00:02:09,926 --> 00:02:10,206 That's awesome. 43 00:02:10,306 --> 00:02:10,666 T.R. Eckler: What it's now. 44 00:02:11,341 --> 00:02:14,071 Mount Sinai, St. Luke's and Roosevelt, they've changed all the 45 00:02:14,071 --> 00:02:17,041 names, but it's still an incredible emergency residency program. 46 00:02:17,251 --> 00:02:21,271 And then Dr. Dan Egan was my assistant program director when I was there, so 47 00:02:21,271 --> 00:02:23,351 this is just a homecoming podcast for me. 48 00:02:23,771 --> 00:02:25,301 Sam: Fantastic. 49 00:02:26,141 --> 00:02:26,411 All right. 50 00:02:26,411 --> 00:02:27,761 Well, let's talk about syphilis then. 51 00:02:27,761 --> 00:02:33,201 So, syphilis, the great masquerader as it's called for a good reason because 52 00:02:33,411 --> 00:02:38,451 it has a multitude of presentations and all of them look different and 53 00:02:38,451 --> 00:02:42,831 all of them look like other diseases can, and so it can be exceptionally 54 00:02:42,831 --> 00:02:45,801 hard to make this diagnosis and. 55 00:02:45,891 --> 00:02:52,068 Just because the US has published data from the CDC saying that cases are 56 00:02:52,068 --> 00:02:56,688 going up, especially congenital syphilis cases and cases have dramatically 57 00:02:56,688 --> 00:02:58,938 increased in specific populations. 58 00:02:58,968 --> 00:03:03,198 And before we go on, if you're listening to this podcast and you have like, 59 00:03:03,378 --> 00:03:06,468 I dunno, children in the vehicle or you're blasting it at home and there's 60 00:03:06,468 --> 00:03:08,748 children around, we're gonna talk about. 61 00:03:09,003 --> 00:03:12,783 Syphilis, which is a transmitted disease, and we're gonna talk 62 00:03:12,783 --> 00:03:13,893 about how it's transmitted. 63 00:03:14,203 --> 00:03:17,813 And so now would be a good time to pop in your headphones or to take 64 00:03:17,813 --> 00:03:19,253 the little ears out of the room. 65 00:03:19,473 --> 00:03:22,533 The rest of the podcast will not be appropriate for children. 66 00:03:23,253 --> 00:03:23,943 Having said that, 67 00:03:24,058 --> 00:03:24,688 T.R. Eckler: pictures though. 68 00:03:24,688 --> 00:03:25,798 Great pictures in the article. 69 00:03:25,798 --> 00:03:26,693 No pictures in the podcast. 70 00:03:27,003 --> 00:03:28,173 Sam: no pictures in the podcast. 71 00:03:28,173 --> 00:03:32,103 But I tell you what, this issue is packed with a multitude of pictures and 72 00:03:32,103 --> 00:03:36,273 some of these things you really need to see to understand how easy it would 73 00:03:36,273 --> 00:03:38,133 be to confuse this for something else. 74 00:03:38,643 --> 00:03:39,063 And. 75 00:03:39,063 --> 00:03:44,586 on the epidemiology note, I was going to say that there's been a 42% 76 00:03:44,586 --> 00:03:49,596 increase in cases, especially in the most vulnerable population, and this 77 00:03:49,596 --> 00:03:53,866 is the men who have sex with other men identify as gay or bisexual. 78 00:03:53,986 --> 00:03:55,006 Those with HIV. 79 00:03:55,326 --> 00:04:00,466 Those on HIV pre-exposure prophylaxis or living with a partner with HIV 80 00:04:00,686 --> 00:04:02,636 that's the highest risk population. 81 00:04:02,856 --> 00:04:05,046 And that's where there's been a significant rise. 82 00:04:05,046 --> 00:04:09,696 But there also has been a large rise in congenital syphilis, so that's cases 83 00:04:09,696 --> 00:04:12,066 going underdiagnosed in pregnant women. 84 00:04:12,386 --> 00:04:16,286 And that's a sad note really because that is a disease that we screen 85 00:04:16,286 --> 00:04:18,816 for with adequate, prenatal care. 86 00:04:19,176 --> 00:04:24,106 But if patients do not have access to prenatal care, then this is where one 87 00:04:24,106 --> 00:04:27,856 of those processes could get missed and where you might be able to catch it in 88 00:04:27,856 --> 00:04:29,206 the ED when they present with their rash, 89 00:04:30,006 --> 00:04:31,896 T.R. Eckler: I'll tell you having, trained in New York City where I 90 00:04:31,896 --> 00:04:37,636 saw a lot of HIV patients, I never saw syphilis in my residency, and I 91 00:04:37,636 --> 00:04:39,106 really have never seen it for years. 92 00:04:39,106 --> 00:04:42,226 But since moving to the South, I've seen more and more of this. 93 00:04:42,441 --> 00:04:45,711 In both primary syphilis, tertiary syphilis, neurosyphilis. 94 00:04:45,991 --> 00:04:49,771 And then just in the last month I've gotten a chance to be a part of a case 95 00:04:49,771 --> 00:04:53,941 where one of my partners diagnosed ocular syphilis, which counts as neurosyphilis. 96 00:04:54,227 --> 00:04:54,307 Sam: Hmm. 97 00:04:54,331 --> 00:04:58,201 T.R. Eckler: And then I just the other day diagnosed a patient with PJP pneumonia 98 00:04:58,411 --> 00:05:00,511 from HIV that was progressing to aids. 99 00:05:00,751 --> 00:05:04,141 And I would tell you that as primary care gets harder to access, and as public 100 00:05:04,141 --> 00:05:08,881 health gets more and more deprioritized I think at a lot of levels of government. 101 00:05:08,881 --> 00:05:13,231 I think as emergency physicians and urgent care physicians, we need to basically 102 00:05:13,231 --> 00:05:16,771 look at this as our time as providers to step up and get more aggressive with 103 00:05:16,771 --> 00:05:19,921 our screening, because more of this is gonna start slipping through the cracks 104 00:05:19,921 --> 00:05:23,801 and it's gonna be, an opportunity for us to catch it and save

these patients from 105 00:05:23,831 --> 00:05:25,751 a really nasty progression of disease. 106 00:05:26,551 --> 00:05:27,121 Sam: Absolutely. 107 00:05:27,211 --> 00:05:29,191 I could not have said it better myself. 108 00:05:29,191 --> 00:05:32,385 That was a, fantastic public service announcement for our 109 00:05:32,385 --> 00:05:33,705 public health colleagues, really. 110 00:05:33,925 --> 00:05:36,985 But also for anyone working in the emergency department or really even 111 00:05:36,985 --> 00:05:39,475 an urgent care center where you might see some of these present. 112 00:05:39,841 --> 00:05:43,871 The highest risk population now really everyone is at risk. 113 00:05:43,901 --> 00:05:45,761 So we talk about highest risk. 114 00:05:45,761 --> 00:05:48,701 This is based purely on numbers, and this is going to be people who 115 00:05:48,701 --> 00:05:52,061 are younger adults, those who have multiple sex partners or engage in 116 00:05:52,061 --> 00:05:54,101 drug use, especially IV drug use. 117 00:05:54,311 --> 00:05:57,451 Those who are incarcerated, those who are homeless or those 118 00:05:57,451 --> 00:05:58,861 who exchange money for sex. 119 00:05:59,031 --> 00:06:01,791 And then there is the population I just mentioned who's had the 120 00:06:01,791 --> 00:06:04,891 largest increase in the us and that's men who have sex with other men. 121 00:06:05,171 --> 00:06:09,371 And then there is the population who live with HIV and are immunosuppressed. 122 00:06:09,531 --> 00:06:13,341 And so as you add up all of these populations, including those who are 123 00:06:13,341 --> 00:06:16,921 pregnant or who don't have access to good prenatal care or infants 124 00:06:16,921 --> 00:06:20,351 who are born outside of the hospital and did not get infant screening, 125 00:06:20,351 --> 00:06:23,741 now we're just starting encompass pretty much the entire population. 126 00:06:23,741 --> 00:06:28,790 So your, threshold for testing should be exceptionally low for everyone really. 127 00:06:29,590 --> 00:06:31,900 T.R. Eckler: I, I would tell you our protocol in-house right now is 128 00:06:31,900 --> 00:06:35,650 to screen all of our psychiatric patients that come in for both 129 00:06:35,650 --> 00:06:37,510 thyroid dysfunction and syphilis. 130 00:06:37,690 --> 00:06:40,210 And I think at first I'd just never seen syphilis, so I was like, 131 00:06:40,240 --> 00:06:42,310 oh, I'm not sure we really need to be doing this for everybody. 132 00:06:42,490 --> 00:06:44,830 But I've seen enough positives come of that process 133 00:06:45,061 --> 00:06:45,241 Sam: Hmm. 134 00:06:45,493 --> 00:06:47,663 T.R. Eckler: that I'm realizing how much more it's starting to 135 00:06:47,693 --> 00:06:49,523 become a bigger and bigger problem. 136 00:06:49,844 --> 00:06:50,084 Sam: Yeah. 137 00:06:50,714 --> 00:06:50,984 All right. 138 00:06:50,984 --> 00:06:53,084 Well, let's talk about what causes syphilis. 139 00:06:53,084 --> 00:06:56,124 So syphilis is caused

by Treponema pallidum. 140 00:06:56,144 --> 00:07:00,814 It's a spirochete, it's a bacterium and it's found only in humans. 141 00:07:00,814 --> 00:07:04,864 We are the reservoir for this bacterium, for this disease. 142 00:07:05,084 --> 00:07:07,244 So we can't blame this on anything else. 143 00:07:07,824 --> 00:07:13,794 It basically lives and thrives off of us, and it has no expressed surface 144 00:07:13,794 --> 00:07:19,209 based proteins, which is if you're into the molecular biology of diseases, 145 00:07:19,209 --> 00:07:22,599 these are the things that allow us to, you know, make antibodies and attack 146 00:07:22,599 --> 00:07:26,079 diseases early, and maybe even make it an ideal vaccine for a disease. 147 00:07:26,229 --> 00:07:27,819 It doesn't display any of those. 148 00:07:28,069 --> 00:07:31,459 And that allows it to slip into the central nervous system pretty 149 00:07:31,459 --> 00:07:35,769 easily, which unfortunately is going to be one of those, phases 150 00:07:35,769 --> 00:07:36,969 we're gonna talk about here soon. 151 00:07:37,249 --> 00:07:39,076 And so it's a nasty little bug. 152 00:07:39,106 --> 00:07:41,296 It's transmitted through contact. 153 00:07:41,296 --> 00:07:46,276 That can be oral, vaginal, anal, or skin to skin from lesions. 154 00:07:46,526 --> 00:07:49,166 And it can be from mother to fetus in utero. 155 00:07:49,376 --> 00:07:53,981 And so that basically covers all gamut of types of transmissions 156 00:07:53,981 --> 00:07:55,221 for pretty much any disease. 157 00:07:55,311 --> 00:07:56,682 Uh, It's not respiratory. 158 00:07:57,332 --> 00:07:59,312 And it can't be transmitted through surfaces. 159 00:07:59,432 --> 00:08:03,282 So as long as you're wearing appropriate PPE and gloves, you are 160 00:08:03,282 --> 00:08:04,992 protected as a healthcare provider. 161 00:08:05,212 --> 00:08:08,602 Interestingly, it has been shown, at least there are some cases of 162 00:08:08,602 --> 00:08:12,532 it being transmitted through blood transfusions and through dialysis. 163 00:08:12,592 --> 00:08:16,922 And so that's just another method that the disease can be passed on. 164 00:08:17,372 --> 00:08:21,902 And unfortunately, previous infection doesn't give you any kind of immunity. 165 00:08:22,277 --> 00:08:26,137 And if anything, becoming reinfected patients are less likely to be 166 00:08:26,137 --> 00:08:29,497 symptomatic, so it just makes it even more challenging if you're 167 00:08:29,497 --> 00:08:30,817 dealing with a repeat infection. 168 00:08:31,247 --> 00:08:34,467 T.R. Eckler: I'm trying to understand how to read these titers is a really important 169 00:08:34,467 --> 00:08:38,457 thing to look at, and it's worth exploring as we talk about this because you're gonna 170 00:08:38,457 --> 00:08:41,277 see more of these patients that have been treated before and have been positive, 171 00:08:41,277 --> 00:08:44,757 and now you need to interpret whether this is a new positive or an old positive. 172 00:08:44,853 --> 00:08:45,363 Sam: Yes. 173 00:08:45,453 --> 00:08:45,723 Yes. 174 00:08:45,723 --> 00:08:48,753 And if there's not a protocol in your department, then hey, pull out this 175 00:08:48,753 --> 00:08:52,383 article, find those clinical pathways and make that your department protocol. 176 00:08:52,443 --> 00:08:55,113 'cause it's already spelled out by the authors very nicely 177 00:08:55,113 --> 00:08:56,703 here as a step-by-step process. 178 00:08:57,503 --> 00:08:58,378 Okay, so syphilis occurs. 179 00:08:59,178 --> 00:09:03,778 Really in, in multiple stages, there's the primary syphilis, which is when they first 180 00:09:03,778 --> 00:09:07,288 get infected, it's somewhere around three to six weeks after the initial infection, 181 00:09:07,288 --> 00:09:09,328 and they have a painless skin lesion. 182 00:09:09,548 --> 00:09:13,298 It's classically described as the chancre, which is supposed to be 183 00:09:13,428 --> 00:09:18,848 initially this papule that then becomes ulcerated and then resolves by itself. 184 00:09:18,938 --> 00:09:19,568 Unfortunately. 185 00:09:20,173 --> 00:09:21,103 It's painless. 186 00:09:21,193 --> 00:09:24,733 And so unless the patient happens to see it, they're not gonna know. 187 00:09:24,913 --> 00:09:28,153 And if it's in an area where they don't usually look because it's sexually 188 00:09:28,153 --> 00:09:31,813 transmitted, then they're gonna be completely unaware this thing is present. 189 00:09:31,813 --> 00:09:36,433 And we as emergency clinicians might have the opportunity to 190 00:09:36,433 --> 00:09:39,463 stumble upon it completely by accident during an examination. 191 00:09:39,733 --> 00:09:42,853 So if you see this thing and it's inconsistent with what you're looking 192 00:09:42,853 --> 00:09:46,633 for, then you just have to have a really low threshold for saying, oh. 193 00:09:46,718 --> 00:09:48,608 You know, maybe we should get you tested. 194 00:09:49,088 --> 00:09:53,558 But that appears somewhere around three to six weeks after initial infection. 195 00:09:53,828 --> 00:09:57,818 And just like any other disease process, there's the classic lesion 196 00:09:57,818 --> 00:10:00,128 and then there's what can also occur. 197 00:10:00,128 --> 00:10:05,258 And if their patient has HIV or a very high spirochete load, they can 198 00:10:05,258 --> 00:10:07,328 get multiple lesions, not just one. 199 00:10:07,328 --> 00:10:09,038 And they can be atypical looking So. 200 00:10:09,638 --> 00:10:12,008 It can be difficult to make the diagnosis, but there is a 201 00:10:12,008 --> 00:10:13,838 good picture in the article. 202 00:10:14,118 --> 00:10:16,278 I encourage you to go take a look at that, figure one. 203 00:10:16,668 --> 00:10:20,178 And that one's actually intraoral, so it's a good picture to go take a peek at. 204 00:10:20,978 --> 00:10:25,988 Secondary syphilis is the rash and it's associated with a prodrome fever, 205 00:10:26,018 --> 00:10:28,118 headache, fatigue, and lymph

adenopathy. 206 00:10:28,338 --> 00:10:33,318 And the most common rash that you see is this red, red, brown, kind 207 00:10:33,318 --> 00:10:37,078 of flat and scaly and diffuse, and again, it's classically described 208 00:10:37,098 --> 00:10:38,898 as being on the hands and feet. 209 00:10:38,928 --> 00:10:42,198 So you see a rash on the hands and the feet, you're thinking 210 00:10:42,198 --> 00:10:43,218 like hand, foot, mouth. 211 00:10:43,278 --> 00:10:47,603 You should also think syphilis because this is one of those diseases that is 212 00:10:47,603 --> 00:10:49,433 supposed to classically present this way. 213 00:10:49,833 --> 00:10:52,533 But unfortunately it can also be more diffused so it's not 214 00:10:52,533 --> 00:10:53,943 isolated to the hands and feet. 215 00:10:53,943 --> 00:10:56,043 It can be generalized all over their body. 216 00:10:56,293 --> 00:11:00,403 Sometimes the lesions can be vesicular, sometimes they can be pustular. 217 00:11:00,653 --> 00:11:03,893 And these are considered like the less typical presentations, 218 00:11:03,893 --> 00:11:08,933 but they're possible and they can occur about four to eight weeks. 219 00:11:09,223 --> 00:11:12,853 After the appearance of the chancre, so the chancre was coming three 220 00:11:12,853 --> 00:11:14,323 to six weeks after the infection. 221 00:11:14,323 --> 00:11:17,653 Now four to eight weeks later, we've got secondary syphilis with 222 00:11:17,653 --> 00:11:19,333 the prodrome of those symptoms. 223 00:11:19,633 --> 00:11:24,733 And if it's untreated, it's going to resolve on its own within a few 224 00:11:24,733 --> 00:11:27,283 weeks to a month and then go away. 225 00:11:27,673 --> 00:11:33,268 And now we're in that problem stage where the patient once again has no awareness 226 00:11:33,358 --> 00:11:34,618 of the disease that they're carrying. 227 00:11:35,418 --> 00:11:37,158 And that brings us to tertiary syphilis. 228 00:11:37,158 --> 00:11:42,108 This is the late stage infection, and this can occur as late as 50 229 00:11:42,108 --> 00:11:46,158 years after the initial infection, which is a ridiculous timeframe, but. 230 00:11:46,278 --> 00:11:49,278 Tertiary infection includes all kinds of things. 231 00:11:49,278 --> 00:11:54,018 Cardiac manifestations like aortic aneurysms, aortic valve insufficiency, 232 00:11:54,048 --> 00:11:56,448 coronary stenosis or myocarditis. 233 00:11:56,848 --> 00:12:00,263 Vaso-occlusive complications like strokes can also occur. 234 00:12:00,533 --> 00:12:02,888 You can get gummatous lesions. 235 00:12:02,888 --> 00:12:07,028 These things are like necrotic, large granulomas with immune 236 00:12:07,028 --> 00:12:09,038 cells and bacteria inside them. 237 00:12:09,218 --> 00:12:11,348 They can be internal, like around the liver. 238 00:12:11,348 --> 00:12:13,448 They can be external and be on the skin. 239 00:12:13,848 --> 00:12:18,818 And patients will sometimes present with altered augmentation like depression 240 00:12:19,008

--> 00:12:24,048 which can occur in neurosyphilis, and we'll get to that in one second. 241 00:12:24,048 --> 00:12:27,498 But before we get to that, there is also a latent stage of syphilis. 242 00:12:27,498 --> 00:12:32,728 So in that up to 50 year gap between secondary and tertiary syphilis you 243 00:12:32,728 --> 00:12:36,668 can get this latent syphilis period where you're completely asymptomatic. 244 00:12:36,728 --> 00:12:40,238 And if it's pretty close to the time of your infection, it's considered early. 245 00:12:40,458 --> 00:12:43,218 If we don't know the time of your infection, or it's been maybe 246 00:12:43,218 --> 00:12:44,598 years, it's considered late. 247 00:12:44,958 --> 00:12:48,821 But that's what we define as the latent syphilis stage. 248 00:12:49,621 --> 00:12:51,781 And then come the interesting ones. 249 00:12:51,841 --> 00:12:53,311 Neurosyphilis is one of those. 250 00:12:53,311 --> 00:12:56,341 So neurosyphilis can cause syphilitic meningitis, which 251 00:12:56,671 --> 00:12:59,401 presents like meningitis, does fever, headache, neck pain. 252 00:12:59,651 --> 00:13:03,071 Patients with HIV, especially those with lower CD four counts have 253 00:13:03,321 --> 00:13:06,801 particular predilection to this disease process, but it can affect 254 00:13:06,801 --> 00:13:09,201 anyone who has untreated syphilis. 255 00:13:09,481 --> 00:13:14,584 And it can also present with headaches and cranial nerve deficits. 256 00:13:14,584 --> 00:13:18,074 So if you're examining somebody who's got cranial nerves six, seven, or eight 257 00:13:18,074 --> 00:13:21,494 as a primary deficit and an isolated symptom, you should also think about 258 00:13:21,494 --> 00:13:26,874 syphilis and it can present as what's called meningo vascular syphilis. 259 00:13:27,124 --> 00:13:31,254 Which occurs early and has this kind of stuttering findings 260 00:13:31,254 --> 00:13:32,484 that lead to a stroke, right? 261 00:13:32,484 --> 00:13:34,674 So this is one of those stroke complications. 262 00:13:35,544 --> 00:13:39,144 It can also present with spinal cord disease, which results in lower 263 00:13:39,144 --> 00:13:43,234 extremity pain and ataxia and this kind of foot slapping gait that they get. 264 00:13:43,534 --> 00:13:47,754 And then you can get seizures and general paresis as well. 265 00:13:47,814 --> 00:13:51,294 And unfortunately you make the diagnosis, you do the lumbar puncture, 266 00:13:51,294 --> 00:13:54,604 you get the CSF, you treat them you might clear the infection, but the 267 00:13:54,604 --> 00:13:56,314 neurological symptoms are permanent. 268 00:13:56,404 --> 00:13:58,114 That's not going to get rid of those. 269 00:13:58,914 --> 00:14:00,594 Then there's congenital syphilis. 270 00:14:00,624 --> 00:14:05,224 Again this is passed from mom to child In utero comes with a 271 00:14:05,224 --> 00:14:08,464 12% higher risk of miscarriage, preterm labor, and stillbirths. 272 00:14:08,804 --> 00:14:11,894 If the fetus survives,

they can present with low birth weight, with 273 00:14:11,894 --> 00:14:16,914 rashes, with condylomas, with just rhinorrhea and hepatomegaly or anemias. 274 00:14:17,104 --> 00:14:20,794 And then that can progress to neurological symptoms like seizures, cranial nerve 275 00:14:20,794 --> 00:14:22,774 deficits, hearing loss or blindness. 276 00:14:22,884 --> 00:14:27,621 And this is something that is screened for at birth in most hospitals. 277 00:14:27,621 --> 00:14:30,481 This is part of that TORCH testing so that it can be caught early 278 00:14:30,481 --> 00:14:33,781 and treated before it leads to permanent neurological deficits. 279 00:14:34,111 --> 00:14:38,821 And if not, then as a pediatrician or primary care physician, you 280 00:14:38,821 --> 00:14:40,531 might see it present later. 281 00:14:40,831 --> 00:14:45,001 And interestingly, one of the ways that it presents is by notching the teeth 282 00:14:45,001 --> 00:14:47,991 in the child giving them an appearance of something called Hutchinson teeth. 283 00:14:48,021 --> 00:14:50,331 There's a picture of that in the article. 284 00:14:50,571 --> 00:14:54,787 And so it can cause deformities in the nose, in the frontal bones , it can 285 00:14:54,787 --> 00:14:57,297 cause otic and ocular abnormalities. 286 00:14:57,297 --> 00:15:00,027 And so some of these may be picked up very, very late by 287 00:15:00,027 --> 00:15:01,897 primary care pediatricians. 288 00:15:02,347 --> 00:15:06,997 And then the diagnosis is made unfortunately way, way later than we want. 289 00:15:07,867 --> 00:15:10,717 And then, as you mentioned, one of your partners made the 290 00:15:10,717 --> 00:15:12,427 diagnosis of ocular syphilis. 291 00:15:12,427 --> 00:15:15,977 This is again, considered a neurosyphilis variant. 292 00:15:16,067 --> 00:15:17,057 Tell me how we pick this up. 293 00:15:17,841 --> 00:15:21,525 T.R. Eckler: Basically a patient that had come in with this known uveitis that 294 00:15:21,525 --> 00:15:25,305 everyone was having trouble figuring out and just with a careful history and, a 295 00:15:25,305 --> 00:15:29,725 high enough, concern for the potential for this being sexually associated. 296 00:15:29,725 --> 00:15:33,385 He ran the RPR test and managed to catch it, and I thought it was just a 297 00:15:33,385 --> 00:15:37,881 really great piece of diagnostic work, that usually it doesn't come from, your 298 00:15:37,881 --> 00:15:40,611 emergency room visits where you've only got a few minutes with the patients. 299 00:15:40,881 --> 00:15:44,341 I thought it was just a really great case of, detective work and also it was 300 00:15:44,341 --> 00:15:47,891 just really interesting to learn how serious this is because it's treated 301 00:15:47,891 --> 00:15:51,791 like neurosyphilis and you've gotta admit 'em for full on IV penicillin, 302 00:15:51,791 --> 00:15:54,341 which we'll kind of talk about as we move into the treatment phase of this. 303 00:15:55,141 --> 00:15:58,181 Sam: Yeah, and

ocular syphilis is you know, if you're talking with 304 00:15:58,181 --> 00:16:00,531 your ophthalmology colleagues, this is gonna be panuveitis. 305 00:16:00,551 --> 00:16:02,111 So not just in one location. 306 00:16:02,271 --> 00:16:05,601 They might have disc edema, they might have retinitis, they might 307 00:16:05,601 --> 00:16:07,191 have an occlusive vasculitis. 308 00:16:07,191 --> 00:16:09,651 So this is kind of the same vascular problem you would get from a 309 00:16:09,651 --> 00:16:11,601 stroke except involving the eye. 310 00:16:11,901 --> 00:16:16,011 And the patients may describe floaters and flashers and even vision loss. 311 00:16:16,341 --> 00:16:20,031 Interestingly, they can get otosyphilis as well, and so this is 312 00:16:20,031 --> 00:16:23,481 syphilis that affects your hearing mechanisms, giving you hearing loss, 313 00:16:23,661 --> 00:16:27,791 both conductive or sensory neural and ringing or tinnitus in your ear. 314 00:16:28,041 --> 00:16:33,383 And ocular syphilis and otosyphilis can be seen with or independent 315 00:16:33,413 --> 00:16:34,823 of classic neurosyphilis. 316 00:16:34,823 --> 00:16:37,853 So this may be their only presentation just to make it 317 00:16:37,943 --> 00:16:39,683 even more difficult to diagnose. 318 00:16:40,483 --> 00:16:40,693 T.R. Eckler: Yep. 319 00:16:40,843 --> 00:16:44,400 And I, just wanna make one case, just as one of the biggest areas they talked 320 00:16:44,400 --> 00:16:48,080 about for being of concern is the increase in newborn diagnosed syphilis. 321 00:16:48,230 --> 00:16:51,890 And I thought that the figures and figure four, the rashes showing like 322 00:16:52,160 --> 00:16:56,480 kind of a non-specific desquamating rash, kind of a pustular rash on a newborn. 323 00:16:56,915 --> 00:17:01,025 Then the more classic macular , copper colored rashes that you can see. 324 00:17:01,025 --> 00:17:03,815 I thought those were helpful because I think if I saw that on a 325 00:17:03,815 --> 00:17:06,575 newborn I, I wouldn't immediately jump to syphilis in my head. 326 00:17:06,575 --> 00:17:09,905 But now I think my pretest concern is significantly higher from that. 327 00:17:10,345 --> 00:17:11,125 Sam: Yeah, yeah. 328 00:17:11,125 --> 00:17:14,745 I really can't stress enough the fantastic figures in this issue. 329 00:17:14,895 --> 00:17:18,045 Like figure six shows the cutaneous and mucosal lesions. 330 00:17:18,045 --> 00:17:20,595 And some of these I could easily see myself glancing 331 00:17:20,595 --> 00:17:22,395 over in physical examination. 332 00:17:22,615 --> 00:17:26,005 Figure seven shows some of the mucosal lesions on the tongue and the lips. 333 00:17:26,005 --> 00:17:29,185 Figure eight shows the skin ulcerations of malignant syphilis. 334 00:17:29,395 --> 00:17:32,425 And these are multiple ulcerated lesions all over the back and 335 00:17:32,425 --> 00:17:34,135 chest in that particular instance. 336 00:17:34,135 --> 00:17:37,325 So I highly recommend you just go take a peek of these and 337 00:17:37,325 --> 00:17:38,975 add them to your armamentarium. 338 00:17:39,775 --> 00:17:43,195 There is a section about differential diagnosis, and really this just 339 00:17:43,195 --> 00:17:47,605 depends on which stage they're in and what it's mimicking. 340 00:17:47,605 --> 00:17:50,425 So, you know, if they're in their primary stage, it's very easy to 341 00:17:50,665 --> 00:17:55,335 just dismiss the rash as primary alopecia, condyloma, psoriasis, 342 00:17:55,335 --> 00:17:57,105 drug eruptions, viral exanthems. 343 00:17:57,385 --> 00:18:01,525 But you just gotta really have that high suspicion, especially in the highest 344 00:18:01,525 --> 00:18:03,695 risk patients that we discussed earlier. 345 00:18:04,025 --> 00:18:07,630 And if you're seeing them in the secondary stage, they've got the rash. 346 00:18:07,630 --> 00:18:11,340 If you're seeing 'em in the tertiary stage then they may present with 347 00:18:11,340 --> 00:18:13,110 that tabes dorsalis that drop foot. 348 00:18:13,140 --> 00:18:16,770 They may have a stroke, they may have multiple sclerosis type symptoms. 349 00:18:16,920 --> 00:18:19,740 They may have neuro deficits or cranial nerve abnormalities. 350 00:18:19,740 --> 00:18:22,005 You're thinking vitamin B12 deficiencies. 351 00:18:22,005 --> 00:18:25,180 And there's lots of other things on the differential that syphilis 352 00:18:25,180 --> 00:18:29,130 mimics and they may have cardiac abnormalities, come in with chest pain. 353 00:18:29,130 --> 00:18:30,210 They may have a new murmur. 354 00:18:30,370 --> 00:18:33,130 You're thinking they've got aortic valve insufficiency or some kind of 355 00:18:33,130 --> 00:18:37,230 coronary stenosis or they present with myocarditis and they don't 356 00:18:37,230 --> 00:18:38,610 have a specific reason to have it. 357 00:18:38,610 --> 00:18:41,220 And, you know, most of those are idiopathic or viral, but you gotta 358 00:18:41,220 --> 00:18:42,780 test them for syphilis to make sure. 359 00:18:43,090 --> 00:18:43,450 So. 360 00:18:43,643 --> 00:18:46,433 There's lots and lots of disease processes on the differential. 361 00:18:46,433 --> 00:18:49,693 Table one has a good one for the skin lesions because if you see the chancre 362 00:18:50,043 --> 00:18:53,663 you gotta think to yourself, okay, is it a painless lesion, you know, 363 00:18:53,663 --> 00:18:55,638 is this person at risk for syphilis. 364 00:18:55,638 --> 00:18:57,798 Should I just go ahead and treat them while we're waiting for testing? 365 00:18:58,128 --> 00:19:04,528 Chancroid, herpes, genital warts initial primary HIV infection, mpox, molluscum. 366 00:19:04,558 --> 00:19:08,338 All of these are on the differential for cutaneous lesions, so just, 367 00:19:08,338 --> 00:19:11,578 be very careful and have a low suspicion and send the testing. 368 00:19:12,378 --> 00:19:15,258 For pre-hospital personnel, there's not a whole lot you're gonna do in 369 00:19:15,258 -->

00:19:17,958 the way of diagnosis for this, but you just gotta make sure you're 370 00:19:17,958 --> 00:19:21,258 wearing your PPE and reduce your chance of exposure because when the 371 00:19:21,258 --> 00:19:24,378 patient is found to have secondary syphilis, that rash is contagious. 372 00:19:24,378 --> 00:19:27,178 Those skin lesions are contagious, so just make sure if they have a 373 00:19:27,178 --> 00:19:30,528 rash, you're wearing your PPE so you don't get yourself exposed. 374 00:19:31,328 --> 00:19:34,548 And then when they're in the ED and we're trying to get a history all 375 00:19:34,548 --> 00:19:36,918 of those risk factors are important. 376 00:19:36,918 --> 00:19:41,268 They're not diagnostic, but they're important and they come into play later 377 00:19:41,268 --> 00:19:44,178 when you're deciding, am I gonna test this person and wait for the results, 378 00:19:44,178 --> 00:19:47,478 or am I just gonna go ahead and treat this person and send the testing and 379 00:19:47,478 --> 00:19:48,978 then somebody else can follow up on it? 380 00:19:49,308 --> 00:19:53,318 So the highest risk features are the ones like men who have sex with other 381 00:19:53,318 --> 00:19:58,298 men, HIV positive patients, those on pre-exposure prophylaxis therapy, those 382 00:19:58,298 --> 00:20:02,883 who trade sex for money and those who are IV drug users, recurrent sexual 383 00:20:02,883 --> 00:20:06,393 transmitted infections, or if you're seeing somebody for a sexually transmitted 384 00:20:06,393 --> 00:20:10,353 infection, you should consider screening them for syphilis as well, because 385 00:20:10,353 --> 00:20:12,393 it can be a concomitant infection. 386 00:20:13,233 --> 00:20:16,233 And if you're seeing somebody who's pregnant and has no prenatal care. 387 00:20:16,868 --> 00:20:18,458 That's another good time to test them as well. 388 00:20:18,458 --> 00:20:21,038 You might be saving two lives in that scenario. 389 00:20:21,158 --> 00:20:24,528 So those are the kinds of things you wanna pull out in the history. 390 00:20:24,898 --> 00:20:28,448 When it comes to examination again, depending on which stage they're in, 391 00:20:28,448 --> 00:20:29,918 you're looking for specific symptoms. 392 00:20:29,918 --> 00:20:31,718 You're looking for the chancre, you're looking for 393 00:20:31,718 --> 00:20:33,278 the rash on the hands and feet. 394 00:20:33,458 --> 00:20:36,398 You're looking for hair loss, especially if it's on the scalp. 395 00:20:36,728 --> 00:20:39,938 If it's tertiary, you're looking for those new onset murmurs or aortic 396 00:20:39,938 --> 00:20:43,958 regurgitation, or in your case, maybe some ocular symptoms that are not 397 00:20:43,958 --> 00:20:47,018 resolved and are kind of been a little bit mysterious and difficult to diagnose. 398 00:20:47,238 --> 00:20:49,748 Hearing loss if they have the otosyphilis. 399 00:20:50,055 --> 00:20:52,215 And then if you're considering things like meningitis or 400 00:20:52,215 --> 00:20:53,535 neurosyphilis, do they have fever? 401 00:20:53,535 --> 00:20:54,435 Do they have a stiff neck? 402 00:20:54,435 --> 00:20:55,275 Do they have headache? 403 00:20:55,555 --> 00:20:58,465 Have you noticed any kind of neurological deficits? 404 00:20:58,475 --> 00:20:59,405 Maybe they're ataxic. 405 00:20:59,405 --> 00:21:02,595 You gotta get 'em up and walk 'em to get that slapping feet gait 406 00:21:02,705 --> 00:21:06,025 and test them for mental status to see, do they have confusion? 407 00:21:06,085 --> 00:21:07,255 Do they have dementia symptoms? 408 00:21:07,255 --> 00:21:08,485 Have they been having seizures? 409 00:21:08,665 --> 00:21:10,135 Is there any history of dementia? 410 00:21:10,135 --> 00:21:14,305 So lots of information you need to extract from the history and physical 411 00:21:14,585 --> 00:21:16,385 before you can make this diagnosis. 412 00:21:16,415 --> 00:21:19,055 But a lot of it will support your suspicion. 413 00:21:19,855 --> 00:21:22,733 T.R. Eckler: The thing that really, I think, pushed me in a couple of cases 414 00:21:22,733 --> 00:21:26,803 that I've seen was just a patient with a horrible rash that had, bad, 415 00:21:26,953 --> 00:21:31,333 tertiary syphilis neurosyphilis that both times the patients were just really 416 00:21:31,333 --> 00:21:35,233 unconcerned about how severe their rash was through their whole body. 417 00:21:35,483 --> 00:21:37,943 you know, there was just such a disconnect between how ill and 418 00:21:37,943 --> 00:21:42,223 sick appearing they looked and how they perceived their health to be. 419 00:21:42,223 --> 00:21:45,313 So I think that that's something to consider if you'd notice kind of a 420 00:21:45,313 --> 00:21:49,683 disconnect between your estimation of the patient's, wellbeing and their appearance. 421 00:21:49,683 --> 00:21:52,653 I think that should also make you stop and think syphilis. 422 00:21:52,774 --> 00:21:53,194 Sam: Mm-hmm. 423 00:21:53,279 --> 00:21:54,069 Mm-hmm. 424 00:21:54,869 --> 00:21:55,109 Okay. 425 00:21:55,109 --> 00:21:56,939 Let's talk about making the diagnosis. 426 00:21:56,939 --> 00:22:00,899 So before we start, just know that every state, that's all 50 states 427 00:22:00,899 --> 00:22:05,249 have rules for mandatory reporting of syphilis to your state or local public 428 00:22:05,249 --> 00:22:08,939 health agency because they'll track these and hopefully track down people 429 00:22:08,939 --> 00:22:14,272 who live with them and partners and do their diligence to try and contain it. 430 00:22:14,762 --> 00:22:17,822 So just know that whatever state you're in, you should have access to that. 431 00:22:17,822 --> 00:22:19,832 But those are mandatory reporting guidelines. 432 00:22:20,252 --> 00:22:23,012 There are multiple types of tests. 433 00:22:23,812 --> 00:22:29,132 And a specific sequence you want to perform them in there are non 434 00:22:29,192 --> 00:22:32,942 treponemal tests, meaning these tests don't detect the

bacteria themselves. 435 00:22:32,972 --> 00:22:35,552 They detect antibodies and usually they're antibodies to the 436 00:22:35,552 --> 00:22:37,172 tissue that's being destructive. 437 00:22:37,382 --> 00:22:39,992 It's not an antibody specifically to the bacterium. 438 00:22:40,242 --> 00:22:44,112 That's your VDRL or RPR test, and that's usually the one that's 439 00:22:44,112 --> 00:22:46,362 available to us to order from the ED. 440 00:22:46,712 --> 00:22:49,622 oftentimes it's not going to come back while they're in their ED stay. 441 00:22:49,622 --> 00:22:51,542 Just kind of depends on how long it is or whether or not 442 00:22:51,542 --> 00:22:52,622 they're going to observation. 443 00:22:52,992 --> 00:22:56,702 But it's a test that may result and it's a titer. 444 00:22:56,762 --> 00:22:59,162 So you gotta know what's abnormal and normal. 445 00:22:59,162 --> 00:23:00,842 Usually that's in your reference ranges. 446 00:23:01,002 --> 00:23:03,762 You gotta look back and see if they've ever tested positive before. 447 00:23:03,952 --> 00:23:08,487 And then if it's positive, move on to a more definitive test. 448 00:23:08,667 --> 00:23:11,237 If it's negative, then they are lower risk. 449 00:23:11,237 --> 00:23:13,987 But just know that there are gonna be scenarios where you get false 450 00:23:13,987 --> 00:23:15,577 negatives and false positives. 451 00:23:16,157 --> 00:23:19,847 The authors mentioned that false negative results can be seen early in infection. 452 00:23:19,847 --> 00:23:22,997 So if they're newly infected, they might not have the antibodies yet. 453 00:23:22,997 --> 00:23:25,757 So your VDRL and RPR are gonna be negative. 454 00:23:25,757 --> 00:23:30,077 So if you highly suspect it, just treat them and then you can retest them later. 455 00:23:30,517 --> 00:23:33,767 Or you can get false positives in patients who don't have syphilis if they 456 00:23:33,767 --> 00:23:35,417 were previously treated for syphilis. 457 00:23:35,417 --> 00:23:40,077 And that's why I say you look back and you see what their prior test results were. 458 00:23:40,297 --> 00:23:42,637 And that doesn't make the tests completely useless. 459 00:23:42,637 --> 00:23:43,807 You can follow titers. 460 00:23:43,967 --> 00:23:46,457 Generally it's a fourfold monitoring. 461 00:23:46,517 --> 00:23:50,297 So if their titer has gone down by fourfold, they're considered to 462 00:23:50,297 --> 00:23:52,247 have been treated and disease free. 463 00:23:52,427 --> 00:23:56,327 And if you repeat it and now the titer has gone up by fourfold, then now you're 464 00:23:56,327 --> 00:24:00,677 considered reinfected and you need to undergo antibiotic therapy again. 465 00:24:00,917 --> 00:24:03,647 So that doesn't make the test useless, but just know it's a titer, you're 466 00:24:03,647 --> 00:24:07,217 gonna get a number, like one to eight, one to four, one to two, one to 64. 467 00:24:07,617 --> 00:24:11,697 And so expect to have to do a little bit of math if they've had previous testing. 468 00:24:12,412 --> 00:24:15,502 T.R. Eckler: It's also worth noting that patients coming from other countries may 469 00:24:15,712 --> 00:24:20,222 test positive in some of these tests, but they have been exposed to other treponemal 470 00:24:20,222 --> 00:24:22,292 infections, not necessarily syphilis. 471 00:24:22,532 --> 00:24:25,922 So again, like you said, it's just keep following the testing, 472 00:24:25,922 --> 00:24:27,272 keep, working the patient up. 473 00:24:27,482 --> 00:24:29,612 Try to make sure that they land with the health department or 474 00:24:29,612 --> 00:24:32,378 with their primary care doctor to, keep interpreting these things. 475 00:24:32,693 --> 00:24:35,873 But more and more of this is gonna kind of land in our lap, so it's 476 00:24:35,873 --> 00:24:38,843 good to understand what the date is that you're looking at, and then 477 00:24:38,843 --> 00:24:40,163 what is the next step that you need? 478 00:24:40,163 --> 00:24:42,023 If you need more clarification from the test. 479 00:24:42,359 --> 00:24:42,599 Sam: Yeah. 480 00:24:43,499 --> 00:24:46,989 And then if that initial test is positive, you're gonna move on to a 481 00:24:46,989 --> 00:24:50,532 next level test, which is typically going to be the antibody test. 482 00:24:50,532 --> 00:24:54,082 And if that's positive, that's considered diagnostic, and then 483 00:24:54,082 --> 00:24:55,552 you're into the treatment section. 484 00:24:55,802 --> 00:24:58,952 There are some PCR tests that are available as well, and those can 485 00:24:58,952 --> 00:25:03,852 take the place of some of that , RPR or VDRL initial testing and can 486 00:25:03,852 --> 00:25:05,172 be a little bit more sensitive. 487 00:25:05,172 --> 00:25:08,182 And so if you're at a facility that has those, just check 488 00:25:08,182 --> 00:25:10,312 whatever your in-house protocol is. 489 00:25:10,582 --> 00:25:14,342 But , the antibody test is considered the treponemal test. 490 00:25:14,342 --> 00:25:18,016 So it's specific for the antibody to Treponema pallidum and it comes 491 00:25:18,076 --> 00:25:23,476 after a initial non treponemal test has been performed and is positive. 492 00:25:24,276 --> 00:25:26,976 And again, that's something that's not going to come back during your ED stay, 493 00:25:26,976 --> 00:25:30,276 so someone's gonna have to follow up on that test, call the patient and give 494 00:25:30,276 --> 00:25:33,246 them that result, and then call them back for treatment if it's positive. 495 00:25:33,536 --> 00:25:35,846 There are, interestingly, a couple of point of care tests 496 00:25:35,846 --> 00:25:38,366 that are now FDA approved that are mentioned by the authors. 497 00:25:38,366 --> 00:25:43,386 The Health Check and DPPV are both tests that can be performed at the point of care 498 00:25:43,486 --> 00:25:48,166 and have shown similar sensitivity and specificity to the non treponemal testing. 499 00:25:48,226 --> 00:25:48,826 So that's.

500 00:25:49,131 --> 00:25:50,091 That's a possibility. 501 00:25:50,091 --> 00:25:52,431 And the patient may have had one at an outpatient clinic already. 502 00:25:52,791 --> 00:25:56,271 And then there's dark field microscopy, so this is where you swab the 503 00:25:56,271 --> 00:25:58,221 lesion and then send it to the lab. 504 00:25:58,411 --> 00:26:01,801 The authors did a good job of, asserting that it's difficult to do 505 00:26:01,861 --> 00:26:05,581 so even the person in your lab might get this wrong, might misinterpret 506 00:26:05,581 --> 00:26:08,651 it but it is a test that can be sent and they're looking specifically 507 00:26:08,651 --> 00:26:11,357 for the, spirochetes on a slide. 508 00:26:11,517 --> 00:26:17,517 And so if you have someone who has a primary chancre you can swab with a 509 00:26:17,637 --> 00:26:21,027 saline moistened cotton tip applicator. 510 00:26:21,177 --> 00:26:24,117 You can swab that lesion and send it to the lab and they can slide 511 00:26:24,117 --> 00:26:27,667 it and try and look if that's positive, that is diagnostic. 512 00:26:27,827 --> 00:26:29,927 And then you can begin treatment, 513 00:26:30,367 --> 00:26:33,093 T.R. Eckler (2): I don't think There's anything quite as cool as the term 514 00:26:33,123 --> 00:26:37,743 dark field microscopy in terms of like what's on your resume as the lab tech. 515 00:26:37,743 --> 00:26:38,583 Like what do you do? 516 00:26:38,703 --> 00:26:40,053 I handle the dark field. 517 00:26:40,743 --> 00:26:43,023 T.R. Eckler: come on, that's, that sounds awesome. 518 00:26:43,073 --> 00:26:45,837 Sam: Oh, my job is dark field microscopy. 519 00:26:46,386 --> 00:26:50,496 T.R. Eckler: Like, like, like I run the gas spectometer, like not, not as cool. 520 00:26:50,496 --> 00:26:51,276 Just not as good. 521 00:26:51,276 --> 00:26:53,136 Like that's gotta be the guy that everybody's like, yo, 522 00:26:53,136 --> 00:26:54,096 that guy does dark field. 523 00:26:54,096 --> 00:26:54,721 Don't mess with him. 524 00:26:54,927 --> 00:26:55,677 Sam: Dark field. 525 00:26:55,737 --> 00:26:56,217 That's right. 526 00:26:56,307 --> 00:26:59,217 The proud, the few, the dark field microscopists. 527 00:27:00,017 --> 00:27:00,317 All right. 528 00:27:00,347 --> 00:27:03,077 You can test other body fluids. 529 00:27:03,077 --> 00:27:06,107 So if you're thinking they have syphilitic meningitis, you need a lumbar puncture, 530 00:27:06,107 --> 00:27:07,907 you take that CSF and you test it. 531 00:27:08,237 --> 00:27:10,537 If you're, diagnosing ocular syphilis. 532 00:27:10,537 --> 00:27:13,627 There really isn't a tissue sample here that you're gonna be able to get. 533 00:27:13,857 --> 00:27:18,960 Same with the o kind of treated based on examination and suspicion 534 00:27:18,960 --> 00:27:21,060 and maybe a positive RPR and VDRL. 535 00:27:21,860 --> 00:27:23,330 Alright, let's get into treatment. 536 00:27:23,390 --> 00:27:27,810 So treatment gets a little complicated and I'll

say a little 537 00:27:27,870 --> 00:27:32,980 because there is historically one treatment and that's penicillin. 538 00:27:33,460 --> 00:27:37,290 And if you are practicing in an ED or urgent care anywhere in the United States 539 00:27:37,290 --> 00:27:40,920 right now, you know that there continues to be a shortage of that medication. 540 00:27:41,260 --> 00:27:45,980 And so even though the US government and the FDA have approved purchasing 541 00:27:45,980 --> 00:27:50,120 of the drug from other countries like France and Spain, we're still short. 542 00:27:50,310 --> 00:27:53,490 And so even though we used to give this out, like it was water, just 543 00:27:53,490 --> 00:27:56,790 based on suspicion, you may have more stringent criteria for administering 544 00:27:56,790 --> 00:27:58,050 this medication in your ED. 545 00:27:58,440 --> 00:28:00,420 You may have to actually have a positive test. 546 00:28:00,450 --> 00:28:04,345 So just be aware that we've been using penicillin since it was 547 00:28:04,345 --> 00:28:05,995 discovered back in the 1920s. 548 00:28:05,995 --> 00:28:09,265 And in about the 1940s is when it was thought, oh, okay. 549 00:28:09,265 --> 00:28:11,695 Somebody discovered, Hey, we can use this for syphilis. 550 00:28:11,915 --> 00:28:13,595 And it keeps people from bouncing back. 551 00:28:13,895 --> 00:28:19,655 The IM route is superior to the IV route, so you actually do not want to give 552 00:28:19,655 --> 00:28:21,635 this IV unless you absolutely have to. 553 00:28:21,635 --> 00:28:24,985 You're treating like Neurosyphilis for an extended period of time on a daily 554 00:28:24,985 --> 00:28:26,605 basis, and they're getting multiple doses. 555 00:28:26,815 --> 00:28:29,405 But the preferred method is IM. 556 00:28:29,535 --> 00:28:31,815 The efficacy there is way better. 557 00:28:32,035 --> 00:28:34,855 And it's a single dose, 2.4 million units for an adult. 558 00:28:35,155 --> 00:28:36,115 Intramuscularly. 559 00:28:36,415 --> 00:28:38,395 Covers you for syphilis. 560 00:28:38,645 --> 00:28:41,195 It does not treat neurosyphilis right? 561 00:28:41,195 --> 00:28:44,045 And it doesn't treat the neurosyphilis related disorders 562 00:28:44,045 --> 00:28:46,235 like the oto or ocular involvement. 563 00:28:46,485 --> 00:28:48,675 But it will treat primary and secondary. 564 00:28:49,125 --> 00:28:50,905 There are first line agents. 565 00:28:50,905 --> 00:28:55,945 Those are penicillin G or benzathine penicillin, or Bicillin L-A 566 00:28:55,945 --> 00:28:57,565 that comes by multiple names. 567 00:28:57,635 --> 00:29:00,035 That's the one that's in the shortage and that the FDA is still 568 00:29:00,035 --> 00:29:03,245 trying to procure samples from France and Portugal and elsewhere. 569 00:29:03,555 --> 00:29:05,565 So if you have access to it, that's great. 570 00:29:05,625 --> 00:29:07,575 It's 2.4 million units IM. 571 00:29:07,735 --> 00:29:14,225 There is a similar preparation, penicillin g procaine, and other 572 00:29:14,225 --> 00:29:18,185 formulations that are oral are not considered sufficient for treatment. 573 00:29:18,495 --> 00:29:22,665 So you might be in the untenable position of trying to figure out, okay, what do 574 00:29:22,665 --> 00:29:24,525 I have at my disposal to treat this? 575 00:29:24,835 --> 00:29:26,005 And a couple of caveats there. 576 00:29:26,005 --> 00:29:29,305 So there's a great table on page 12 that goes through the 577 00:29:29,305 --> 00:29:31,255 medications and dosages for syphilis. 578 00:29:31,535 --> 00:29:33,965 Know that if they're pregnant, there are no other options. 579 00:29:34,175 --> 00:29:36,515 It's penicillin or penicillin or penicillin. 580 00:29:36,635 --> 00:29:40,475 And if they're penicillin allergic, they have to go through desensitization therapy 581 00:29:40,565 --> 00:29:43,585 and then get the full dose while pregnant. 582 00:29:43,675 --> 00:29:46,915 And I cannot think of anything more terrible than having to do that. 583 00:29:47,425 --> 00:29:49,495 But just know that if they're pregnant, it's that. 584 00:29:49,595 --> 00:29:53,525 If they're not pregnant, there are some second line agents. 585 00:29:53,555 --> 00:29:57,505 Thankfully, there is limited evidence that doxycycline a hundred milligrams 586 00:29:57,505 --> 00:30:02,685 orally twice a day for 14 days or tetracycline may actually work. 587 00:30:02,935 --> 00:30:08,405 And when I say may, like the evidence says that one study showed it was about 82.9% 588 00:30:08,435 --> 00:30:11,810 efficacious versus 97% for penicillin. 589 00:30:11,840 --> 00:30:13,250 So it's pretty close. 590 00:30:13,250 --> 00:30:15,260 It's not a hundred percent, but it's pretty close. 591 00:30:15,590 --> 00:30:21,530 There is also some evidence that Ceftriaxone given daily as an IM injection 592 00:30:21,690 --> 00:30:25,920 is also efficacious, has a cure rate of somewhere between 65 and a hundred percent 593 00:30:25,920 --> 00:30:27,840 depending on which study you look at. 594 00:30:27,840 --> 00:30:31,230 And so the CDC lists it as an alternative to IM penicillin 595 00:30:31,450 --> 00:30:32,530 if there's none available. 596 00:30:32,740 --> 00:30:36,230 So those are your only two other options you get. 597 00:30:37,150 --> 00:30:41,845 IM penicillin, 2.4 million units or doxycycline or maybe 598 00:30:42,085 --> 00:30:44,245 ceftriaxone, as an alternative. 599 00:30:44,525 --> 00:30:47,555 and that's all for primary and secondary and early latent. 600 00:30:47,615 --> 00:30:53,548 If you've got late stage latent syphilis it's, IM or doxycycline. 601 00:30:53,668 --> 00:30:57,508 If you've got tertiary syphilis, it's, again, IM penicillin. 602 00:30:57,598 --> 00:30:58,618 No other choices. 603 00:30:58,618 --> 00:31:03,958 If you've got Neurosyphilis, now we're into the IV therapy extended course. 604 00:31:04,028 --> 00:31:04,198 And. 605 00:31:04,583 --> 00:31:07,943 If they're pregnant, of course you're treating that with just

penicillin. 606 00:31:08,283 --> 00:31:11,223 The little ones, if they've got congenital syphilis, again, it's 607 00:31:11,223 --> 00:31:13,233 penicillin, no secondary options. 608 00:31:13,233 --> 00:31:17,073 So really, your, alternative drugs exist for primary and secondary 609 00:31:17,073 --> 00:31:18,783 and maybe early, late in syphilis. 610 00:31:19,593 --> 00:31:23,603 When you are treating patients with syphilis you gotta be aware of the 611 00:31:23,603 --> 00:31:27,247 Jarisch–Herxheimer reaction, which is, you know, especially if they're in secondary 612 00:31:27,247 --> 00:31:30,307 syphilis and they've got a high treponemal load and you give them that penicillin, 613 00:31:30,472 --> 00:31:33,562 all that bacterium dies and they can present with something that looks like 614 00:31:33,562 --> 00:31:35,452 anaphylaxis or acute allergic reaction. 615 00:31:35,702 --> 00:31:38,012 And you just gotta recognize that it is not an allergic 616 00:31:38,012 --> 00:31:39,062 reaction to the penicillin. 617 00:31:39,366 --> 00:31:42,306 uh, Headache, myalgias, and even fever can occur. 618 00:31:42,526 --> 00:31:45,736 You gotta caution the patient that this may occur and this is all of that 619 00:31:45,736 --> 00:31:50,516 bacterium in their body dying and it is not a life-threatening allergic reaction. 620 00:31:50,975 --> 00:31:53,645 T.R. Eckler: I actually have the other version of this where I diagnosed 621 00:31:53,645 --> 00:31:57,215 someone with syphilis because someone gave them penicillin for a dental 622 00:31:57,215 --> 00:32:00,755 infection and they got a rash and flu-like symptoms, and I said. 623 00:32:01,655 --> 00:32:04,485 Boy, this doesn't seem like allergic reaction. 624 00:32:04,485 --> 00:32:07,795 It kind of seems more like, you know something's working on something here. 625 00:32:07,915 --> 00:32:11,765 And I remember the term Jarisch–Herxheimer and I looked it up and said, I'm 626 00:32:11,765 --> 00:32:14,255 just gonna send some tests off, but I just wanna make sure this isn't 627 00:32:14,255 --> 00:32:15,425 some other kind of an infection. 628 00:32:15,515 --> 00:32:16,475 And God bless it. 629 00:32:16,475 --> 00:32:20,180 We caught a syphilis case there from just a, a dental infection and a rash. 630 00:32:20,606 --> 00:32:21,626 Sam: Great news. 631 00:32:22,421 --> 00:32:25,001 You don't have a dental infection. 632 00:32:25,385 --> 00:32:27,535 T.R. Eckler: You're not allergic to penicillin like everybody 633 00:32:27,581 --> 00:32:28,271 Sam: That's right. 634 00:32:28,475 --> 00:32:30,425 T.R. Eckler: other news, you have syphilis and you're 635 00:32:30,501 --> 00:32:32,801 Sam: Even better news, your dentist cured your syphilis. 636 00:32:33,601 --> 00:32:35,971 T.R. Eckler: Well, they, I think they, they did not cure it 637 00:32:36,001 --> 00:32:39,271 'cause the oral penicillin is not enough, but they at least gave us 638 00:32:39,271 --> 00:32:40,981 the opportunity to diagnose it. 639 00:32:41,001 --> 00:32:41,451 Sam: There you go. 640 00:32:41,501 --> 00:32:41,971 There you go. 641 00:32:41,991 --> 00:32:42,501 Well said. 642 00:32:42,651 --> 00:32:43,071 Well said. 643 00:32:43,101 --> 00:32:43,521 Wow. 644 00:32:45,311 --> 00:32:45,947 T.R. Eckler: free toothpaste to that dentist. 645 00:32:45,947 --> 00:32:46,201 Free toothpaste. 646 00:32:46,251 --> 00:32:46,671 Sam: That's right. 647 00:32:47,031 --> 00:32:50,121 Nine out of 10 dentists recommend penicillin for syphilis. 648 00:32:50,181 --> 00:32:51,021 That's fantastic. 649 00:32:51,821 --> 00:32:53,231 Okay, let's talk about treatment. 650 00:32:53,471 --> 00:32:55,421 When, when we're talking about treatment, obviously if you have a high 651 00:32:55,421 --> 00:32:59,031 suspicion and you have access to the medication treatment is recommended. 652 00:32:59,311 --> 00:33:02,401 Treatment of sexual partners is highly recommended. 653 00:33:02,401 --> 00:33:05,371 So, you know, all sexual partners in the last 90 days 654 00:33:05,371 --> 00:33:07,111 should be screened and treated. 655 00:33:07,271 --> 00:33:10,751 Any sexual partner beyond 90 days should at the very least be tested. 656 00:33:10,971 --> 00:33:13,641 If they're exceptionally high risk in that category we discussed 657 00:33:13,641 --> 00:33:15,361 before they should just be treated. 658 00:33:15,426 --> 00:33:16,116 Period. 659 00:33:16,366 --> 00:33:22,326 And if they have had a sexual encounter within three months of somebody with 660 00:33:22,326 --> 00:33:25,806 primary syphilis within six months of somebody with secondary syphilis, or 661 00:33:25,806 --> 00:33:30,796 within a year of somebody with latent syphilis, they just need to be tested and 662 00:33:30,796 --> 00:33:33,166 then treated depending on what that shows. 663 00:33:33,166 --> 00:33:35,156 So testing at the very least. 664 00:33:35,246 --> 00:33:38,156 And if they're high risk, just go ahead and treat with whatever 665 00:33:38,156 --> 00:33:39,446 you have available to you. 666 00:33:40,246 --> 00:33:44,116 I wanna pause for one second and just say there's an excellent discussion in 667 00:33:44,116 --> 00:33:48,596 the article in the controversy section about the Tuskegee study, we really, we 668 00:33:48,596 --> 00:33:53,046 can't talk about syphilis without talking about the Tuskegee study because it's 669 00:33:53,046 --> 00:33:58,726 kind of a dark moment in the history of medicine and it really brings to light 670 00:33:58,756 --> 00:34:03,376 some of the, issues around informed consent that we have today in studies and 671 00:34:03,376 --> 00:34:06,736 some of the challenges we have today in studies because we've gone back, looked 672 00:34:06,736 --> 00:34:08,656 at this dark moment in our own history. 673 00:34:08,656 --> 00:34:11,146 We admit it was a terrible thing to do. 674 00:34:11,296 --> 00:34:14,066 And if you've never heard of it, the Tuskegee study occurred. 675 00:34:14,246 --> 00:34:19,926 In the United States

by the Public Health Service between 1932 and 1972. 676 00:34:19,926 --> 00:34:21,696 So this is really not that long ago. 677 00:34:22,006 --> 00:34:26,836 And although at the time that they started the study, there was some evidence already 678 00:34:26,956 --> 00:34:29,176 about the natural course of syphilis. 679 00:34:29,456 --> 00:34:31,196 The study continued. 680 00:34:31,196 --> 00:34:35,756 It enrolled 600 black men in Macon County, Alabama, really not far 681 00:34:35,756 --> 00:34:37,406 from where I'm sitting right now. 682 00:34:37,776 --> 00:34:42,526 And 412 of them had syphilis and the rest were considered controls, 683 00:34:42,886 --> 00:34:48,296 and despite the existence of a known treatment, penicillin, for the syphilis, 684 00:34:48,716 --> 00:34:51,836 these enrollees were left untreated. 685 00:34:52,496 --> 00:34:58,476 They were given vitamins and aspirin as placebos, and were led to believe that 686 00:34:58,476 --> 00:35:00,366 this treatment was for their infection. 687 00:35:00,366 --> 00:35:04,206 But actually what the authors were doing was just observing the natural 688 00:35:04,206 --> 00:35:06,006 history of syphilis infection. 689 00:35:06,346 --> 00:35:12,116 And then they were subjected to procedures like lumbar punctures under the guise 690 00:35:12,116 --> 00:35:15,566 that this was part of their therapy, when again, all that was being done was samples 691 00:35:15,566 --> 00:35:20,546 were being collected and tested to look at the natural progression of neurosyphilis. 692 00:35:21,206 --> 00:35:25,676 The study was started just prior to penicillin therapy becoming widely 693 00:35:25,676 --> 00:35:30,966 available, but continued long after, into the 1970s long after penicillin 694 00:35:30,966 --> 00:35:32,796 treatment had become widely accepted. 695 00:35:33,106 --> 00:35:37,576 The results of the study were exactly what we expected and what we already 696 00:35:37,576 --> 00:35:42,456 knew before the study started about the morbidity and mortality associated 697 00:35:42,456 --> 00:35:47,176 with syphilis and about how the disease progresses into later stages and 698 00:35:47,926 --> 00:35:52,246 unfortunately, although the Tuskegee study is the most well-known, really 699 00:35:52,246 --> 00:35:57,926 controversial, the most well-known, controversial study of syphilis there was 700 00:35:57,926 --> 00:36:03,276 another one, another group of researchers between 1946 and 1948 that that same group 701 00:36:03,386 --> 00:36:09,926 infected a large population in Guatemala, 5,500 people with syphilis gonorrhea. 702 00:36:10,591 --> 00:36:15,026 And or Chancroid, and again, watched them for the natural history. 703 00:36:15,276 --> 00:36:18,456 They were selected from vulnerable populations, prisoners, 704 00:36:18,736 --> 00:36:22,066 orphanages, mental health centers, health clinics, sex workers. 705 00:36:22,066 --> 00:36:25,726 They were inoculated with diseases in order to evaluate whether penicillin 706 00:36:25,796 --> 00:36:30,366 was effective as a pretreatment to prevent syphilis and to evaluate 707 00:36:30,366 --> 00:36:32,766 whether the patients who were previously treated with penicillin 708 00:36:32,826 --> 00:36:34,686 could get repeat syphilis infections. 709 00:36:35,016 --> 00:36:37,926 That study was actually never formally published, but came to 710 00:36:37,926 --> 00:36:42,406 light when the journals of Dr. John Charles Cutler were published. 711 00:36:42,596 --> 00:36:44,996 And he was a participant in both of those experiments, the 712 00:36:44,996 --> 00:36:46,796 Tuskegee and the Guatemala studies. 713 00:36:46,796 --> 00:36:52,496 So a very, very dark period in medicine, but a very important historical note 714 00:36:52,556 --> 00:36:56,566 about what we know and what we know we're not supposed to be doing in 715 00:36:56,566 --> 00:37:01,706 medicine and about the Hippocratic Oath we take and why informed consent is 716 00:37:01,706 --> 00:37:03,596 such an important thing in medicine. 717 00:37:04,236 --> 00:37:07,426 And about the, just really the tragedy that those 600 men in 718 00:37:07,426 --> 00:37:11,216 Macon County underwent as they were just watched, really dying 719 00:37:11,216 --> 00:37:12,506 from their syphilis infections. 720 00:37:12,566 --> 00:37:15,036 So a very, very important historical point. 721 00:37:15,794 --> 00:37:17,144 T.R. Eckler: Can I make one positive, 722 00:37:17,225 --> 00:37:17,515 Sam: yeah. 723 00:37:17,774 --> 00:37:18,434 T.R. Eckler: note on this, 724 00:37:18,434 --> 00:37:22,134 so I can't agree with you more that it's really important to understand 725 00:37:22,134 --> 00:37:26,074 that especially as we, are entering again, a time of deemphasis on public 726 00:37:26,074 --> 00:37:27,814 health and on the scientific process. 727 00:37:27,814 --> 00:37:33,009 I think this is a really important lesson to make sure everyone remembers as to 728 00:37:33,019 --> 00:37:37,819 the slippery slope of how you start off trying to help people and then eventually 729 00:37:37,819 --> 00:37:39,419 end up in, in a very dark place. 730 00:37:39,419 --> 00:37:43,998 But I think a positive other side of this coin is the book Miracle Cure by William 731 00:37:43,998 --> 00:37:48,738 Rosen about basically like the history of how penicillin came to be a treatment and 732 00:37:48,738 --> 00:37:52,458 how it was, you know, discovered years before it was ever considered that it 733 00:37:52,473 --> 00:37:54,738 could be employed for treating people. 734 00:37:54,918 --> 00:37:58,383 And then the interesting period after that where we were mixing all kinds 735 00:37:58,383 --> 00:38:01,673 of antibiotics together and selling them to the public as like, a miracle 736 00:38:01,673 --> 00:38:03,173 cure that, could fix everything. 737 00:38:03,363 --> 00:38:07,743 And kind of the recommitment multiple times in that process to the scientific 738 00:38:07,743 --> 00:38:12,193 process and trying to go

through and see exactly what actually did work to 739 00:38:12,193 --> 00:38:13,963 help people and what did treat disease. 740 00:38:14,203 --> 00:38:17,208 It's a great thing to look at in the history of medicine and to look at just 741 00:38:17,208 --> 00:38:21,253 how incredible it is because that is still the treatment we're using today 742 00:38:21,253 --> 00:38:25,543 for syphilis, and it's still enormously effective and really doing a ton to 743 00:38:25,543 --> 00:38:30,103 save lives that before this we were giving mercury and arsenic and all 744 00:38:30,103 --> 00:38:31,523 kinds of horrible, poisonous things 745 00:38:31,539 --> 00:38:31,959 Sam: Mm-hmm. 746 00:38:32,483 --> 00:38:35,273 T.R. Eckler: I think it's a cool thing when you get frustrated by some of the 747 00:38:35,273 --> 00:38:38,213 challenges in medicine today to look at a process like that and realize that 748 00:38:38,333 --> 00:38:41,603 we're still having an incredible time where we can cure disease when before 749 00:38:41,813 --> 00:38:45,393 you could just kind of watch it and offer some things that might have a 750 00:38:45,393 --> 00:38:46,683 chance of making it a little better. 751 00:38:47,079 --> 00:38:47,319 Sam: Yeah. 752 00:38:47,709 --> 00:38:47,799 Yeah. 753 00:38:47,799 --> 00:38:48,204 Well said. 754 00:38:49,004 --> 00:38:51,674 And there is a section at the very end of the article on 755 00:38:51,734 --> 00:38:53,324 kind of cutting edge therapies. 756 00:38:53,354 --> 00:38:57,464 One of them is whether or not we have alternative treatments 757 00:38:57,464 --> 00:38:58,484 coming down the pipeline. 758 00:38:58,484 --> 00:39:02,204 And there is some published data about oral cefixime, which 759 00:39:02,204 --> 00:39:03,944 I thought was pretty positive. 760 00:39:03,974 --> 00:39:08,024 Uh, Published in studies with men and non-pregnant women. 761 00:39:08,484 --> 00:39:13,414 Showing some pretty decent promises, about a 87% efficacy in treating syphilis. 762 00:39:13,634 --> 00:39:17,414 That's in the, anywhere from the primary, through the early latent 763 00:39:17,414 --> 00:39:21,654 stages which is pretty close really to what you get from doxycycline. 764 00:39:21,714 --> 00:39:24,434 So it is probably an option. 765 00:39:24,464 --> 00:39:27,404 There is limited evidence 'cause the studies are small, but hopefully 766 00:39:27,404 --> 00:39:30,384 that's something that will get studied more and we'll be able 767 00:39:30,384 --> 00:39:32,214 to use that as an option as well. 768 00:39:33,014 --> 00:39:35,894 And then there's a discussion about post-exposure prophylaxis. 769 00:39:35,894 --> 00:39:42,794 So again, limited evidence, but suggesting that a one-time 200 milligram oral dose 770 00:39:42,794 --> 00:39:49,224 of doxycycline, ideally within 24 hours, but up to 72 hours after exposure reduces 771 00:39:49,344 --> 00:39:54,714 the combined risk of gonorrhea, chlamydia, and syphilis by two thirds, which I 772 00:39:54,714 --> 00:39:56,424 thought was pretty amazing, honestly. 773 00:39:56,868 --> 00:39:59,630 T.R. Eckler: So this, immediately entered into something that I would 774 00:39:59,630 --> 00:40:03,880 think about offering to patients because I think that there's not much 775 00:40:03,880 --> 00:40:08,500 downside, and I think that I'm usually basically giving ceftriaxone and then 776 00:40:08,500 --> 00:40:10,150 writing a prescription for the doxy. 777 00:40:10,360 --> 00:40:14,590 But I would now think of changing that to, Hey, here's your ceftriaxone 778 00:40:14,620 --> 00:40:16,330 and here's a dose of doxy here. 779 00:40:16,480 --> 00:40:19,720 With the idea being, I'm not sure you'll ever pick up this prescription, but at 780 00:40:19,720 --> 00:40:23,440 least I know that if I gave you one shot and a pill, I'm really reducing your 781 00:40:23,440 --> 00:40:27,670 chance of developing gonorrhea, syphilis, or chlamydia with just one shot, one pill. 782 00:40:27,915 --> 00:40:28,205 Sam: Yeah. 783 00:40:28,785 --> 00:40:31,155 T.R. Eckler: and just again, let's put something in the 784 00:40:31,155 --> 00:40:33,315 Hall of Fame for study titling. 785 00:40:33,315 --> 00:40:37,605 In the era of so many complicated, silly titles for studies, doxy Pep 786 00:40:37,755 --> 00:40:42,555 is beautiful, clear, and explains exactly what the study looked at and 787 00:40:42,555 --> 00:40:45,285 exactly how much of a great idea it is. 788 00:40:45,285 --> 00:40:49,575 So first of all, just round of applause for those authors and that study. 789 00:40:49,635 --> 00:40:53,025 And I would like to personally offer to fund their follow-up study that's 790 00:40:53,025 --> 00:40:54,285 gonna make this standard of care. 791 00:40:54,435 --> 00:40:56,385 'cause it sounds like they're really close to getting there. 792 00:40:56,675 --> 00:40:57,065 Sam: That's right. 793 00:40:57,215 --> 00:40:57,545 That's right. 794 00:40:57,545 --> 00:41:02,045 It's gonna be called the Eckler STI study or the Eckler protocol. 795 00:41:02,045 --> 00:41:03,665 It's gonna be just one tablet of doxy. 796 00:41:04,370 --> 00:41:04,855 T.R. Eckler: Uh, No. 797 00:41:04,855 --> 00:41:08,665 The Eckler protocol remains Suboxone for patients that get Narcan and 798 00:41:08,665 --> 00:41:10,045 want to immediately be discharged. 799 00:41:10,225 --> 00:41:13,525 And I say, Hey if you wanna go right now, you can, but you've 800 00:41:13,525 --> 00:41:14,785 gotta take this suboxone. 801 00:41:14,785 --> 00:41:16,159 And I really wouldn't recommend that. 802 00:41:16,582 --> 00:41:18,862 Sam: all right, ladies and gentlemen, well that brings us to the end. 803 00:41:18,892 --> 00:41:21,712 Things to remember, five things that will change your practice. 804 00:41:21,712 --> 00:41:25,972 Syphilis is very prevalent and unfortunately on the rise, especially 805 00:41:25,972 --> 00:41:27,382 in those high risk populations. 806 00:41:27,382 --> 00:41:29,692 So keep that in the forefront of your mind.

807 00:41:29,972 --> 00:41:33,487 Patients on pre-exposure prophylaxis are at the highest 808 00:41:33,487 --> 00:41:35,077 risk for syphilis infection. 809 00:41:35,327 --> 00:41:39,897 There is a national shortage of IM benzathine, penicillin G. So if your 810 00:41:39,897 --> 00:41:43,437 hospital doesn't already have a protocol for it, maybe consider doxycycline 811 00:41:43,467 --> 00:41:45,397 as a possible second line agent. 812 00:41:45,617 --> 00:41:49,937 Remember the chancre three to six weeks after infection and then secondary 813 00:41:49,937 --> 00:41:51,977 syphilis four to eight weeks later. 814 00:41:52,257 --> 00:41:55,017 And it's often missed in those high risk populations. 815 00:41:55,347 --> 00:41:58,087 And go and claim your CME. 816 00:41:58,087 --> 00:42:02,467 So if you are a subscriber, know that each one of these issues comes with 817 00:42:02,467 --> 00:42:06,727 four hours of CME for the amount of time that you spend reading, digesting, 818 00:42:06,877 --> 00:42:10,097 and learning about the topic and reviewing those clinical pathways. 819 00:42:10,127 --> 00:42:13,877 So two clinical pathways in the back of this article are great for your 820 00:42:13,877 --> 00:42:16,007 hospital and for your personal practice. 821 00:42:16,057 --> 00:42:18,877 And the link to the CME test will be in the show notes. 822 00:42:18,877 --> 00:42:22,207 So after listening to this episode, you can go and take 823 00:42:22,207 --> 00:42:23,587 that test and get your credit. 824 00:42:24,263 --> 00:42:27,383 T.R. Eckler: could not more strongly recommend how easy it is to get 825 00:42:27,593 --> 00:42:29,963 a lot of CME from these articles. 826 00:42:29,963 --> 00:42:34,703 I think it's the best value in terms of time put in for information that 827 00:42:34,703 --> 00:42:38,323 you actually learn and how fast you get the credit for the CME that you earn.. 828 00:42:39,113 --> 00:42:42,983 Sam: There you go, ladies and gentlemen, from the mouth of Dr. Eckler himself. 829 00:42:43,783 --> 00:42:47,593 And that brings us to the end January, 2026, emergency Medicine Practice 830 00:42:47,593 --> 00:42:51,523 article from Dr. Beason and Dr. He, emergency department diagnosis and 831 00:42:51,523 --> 00:42:53,413 management of patients with syphilis. 832 00:42:53,533 --> 00:42:59,623 And until next time, everyone, be careful wear your PPE and be safe. 833 00:43:00,023 --> 00:43:01,578 T.R. Eckler (2): Penicillin Shots for Everybody. 834 00:43:02,698 --> 00:43:03,868 Sam: Just put it in your drinks 835 00:43:05,828 --> 00:43:07,388 T.R. Eckler: Everybody shots all the time. 836 00:43:07,498 --> 00:43:08,128 Sam: all the time. 837 00:43:08,928 --> 00:43:09,228 All right. 838 00:43:09,228 --> 00:43:09,828 Bye-bye everyone. 839 00:43:10,561 --> 00:43:12,381 Sam : And that's a wrap for this month's episode. 840 00:43:12,421 --> 00:43:15,001 I hope you found it educational and informative. 841 00:43:15,201 --> 00:43:20,061 Don't forget to go to ebmedicine.net to read the article and claim your CME. 842 00:43:20,231 --> 00:43:23,421 And of course, check out all three of the journals and the multitude of 843 00:43:23,421 --> 00:43:27,781 resources available to you, both for emergency medicine, pediatric emergency 844 00:43:27,781 --> 00:43:30,051 medicine, and evidence based urgent care. 845 00:43:30,361 --> 00:43:32,331 Until next time, everyone be safe.