Syphilis: The Great Masquerader

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T.R. Eckler (2): I don't think There's
anything quite as cool as the term
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dark field microscopy in terms of like
what's on your resume as the lab tech.
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Like what do you do?
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I handle the dark field.
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Sam : Hi everyone, and welcome
to another episode of EMPlify
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I'm your host, Sam Ashoo.
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Before we dive into this month's episode,
I want to say thank you for joining us.
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I sincerely hope that you find it to
be helpful and informative for your
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clinical practice, and I want to remind
you that you can go to ebmedicine.net
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where you will find our three journals,
Emergency Medicine Practice, Pediatric
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Emergency Medicine Practice, and Evidence
Based Urgent Care, and a multitude of
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other resources, like the EKG course,
the laceration course, interactive
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clinical pathways, just tons of
information to support your practice
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and help you in your patient care.
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And now, let's jump into
this month's episode.
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Sam: All right, ladies and
gentlemen, welcome back to
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another episode of EMPlify.
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I am one of your hosts, Sam Ashoo, and
on the other end of the microphone,
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T.R. Eckler: Dr. TR Eckler could
not be more excited to be here.
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I'm sick, it's my birthday and I wanna
talk about syphilis, and that just seems
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like a really great summary of my life.
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Sam: Happy birthday.
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Today is the day and I can't think
of celebrating it in a better
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way than talking about syphilis.
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T.R. Eckler: Let's, let's go.
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Sam: We are discussing the January 2026.
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This is the inaugural episode of
the podcast for the year 2026.
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T.R. Eckler: I was like
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podcast did.
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Sam: no, no, no, no.
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Sponsored by, no.
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Today we're talking about the emergency
medicine practice article by Dr.
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Beason and Dr. He.
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This was published in January of this
year on the emergency department diagnosis
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and management of patients with syphilis.
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And I think if you have read the article
or are going to read the article, the
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best summary would be everything you see
is syphilis and everyone should just be
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drinking penicillin on a daily basis.
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T.R. Eckler: I feel especially
qualified to celebrate and appreciate
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this article because Dr. Chen, he
was my chief when I was an intern in
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Sam: No way.
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That's awesome.
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T.R. Eckler: What it's now.
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Mount Sinai, St. Luke's and
Roosevelt, they've changed all the
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names, but it's still an incredible
emergency residency program.
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And then Dr. Dan Egan was my assistant
program director when I was there, so
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this is just a homecoming podcast for me.
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Sam: Fantastic.
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All right.
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Well, let's talk about syphilis then.
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So, syphilis, the great masquerader as
it's called for a good reason because
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it has a multitude of presentations
and all of them look different and
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all of them look like other diseases
can, and so it can be exceptionally
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hard to make this diagnosis and.
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Just because the US has published data
from the CDC saying that cases are
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going up, especially congenital syphilis
cases and cases have dramatically
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increased in specific populations.
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And before we go on, if you're listening
to this podcast and you have like,
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I dunno, children in the vehicle or
you're blasting it at home and there's
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children around, we're gonna talk about.
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Syphilis, which is a transmitted
disease, and we're gonna talk
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about how it's transmitted.
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And so now would be a good time to
pop in your headphones or to take
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the little ears out of the room.
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The rest of the podcast will
not be appropriate for children.
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Having said that,
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T.R. Eckler: pictures though.
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Great pictures in the article.
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No pictures in the podcast.
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Sam: no pictures in the podcast.
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But I tell you what, this issue is
packed with a multitude of pictures and
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some of these things you really need
to see to understand how easy it would
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be to confuse this for something else.
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And.
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on the epidemiology note, I was
going to say that there's been a 42%
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increase in cases, especially in the
most vulnerable population, and this
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is the men who have sex with other
men identify as gay or bisexual.
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Those with HIV.
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Those on HIV pre-exposure prophylaxis
or living with a partner with HIV
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that's the highest risk population.
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And that's where there's
been a significant rise.
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But there also has been a large rise
in congenital syphilis, so that's cases
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going underdiagnosed in pregnant women.
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And that's a sad note really because
that is a disease that we screen
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for with adequate, prenatal care.
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But if patients do not have access to
prenatal care, then this is where one
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of those processes could get missed and
where you might be able to catch it in
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the ED when they present with their rash,
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T.R. Eckler: I'll tell you having,
trained in New York City where I
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saw a lot of HIV patients, I never
saw syphilis in my residency, and I
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really have never seen it for years.
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But since moving to the South,
I've seen more and more of this.
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In both primary syphilis,
tertiary syphilis, neurosyphilis.
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And then just in the last month I've
gotten a chance to be a part of a case
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where one of my partners diagnosed ocular
syphilis, which counts as neurosyphilis.
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Sam: Hmm.
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T.R. Eckler: And then I just the other
day diagnosed a patient with PJP pneumonia
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from HIV that was progressing to aids.
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And I would tell you that as primary
care gets harder to access, and as public
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health gets more and more deprioritized
I think at a lot of levels of government.
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I think as emergency physicians and urgent
care physicians, we need to basically
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look at this as our time as providers
to step up and get more aggressive with
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our screening, because more of this is
gonna start slipping through the cracks
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and it's gonna be, an opportunity for us
to catch it and save these patients from
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a really nasty progression of disease.
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Sam: Absolutely.
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I could not have said it better myself.
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That was a, fantastic public
service announcement for our
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public health colleagues, really.
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But also for anyone working in the
emergency department or really even
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an urgent care center where you
might see some of these present.
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The highest risk population
now really everyone is at risk.
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So we talk about highest risk.
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This is based purely on numbers,
and this is going to be people who
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are younger adults, those who have
multiple sex partners or engage in
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drug use, especially IV drug use.
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Those who are incarcerated,
those who are homeless or those
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who exchange money for sex.
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And then there is the population
I just mentioned who's had the
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largest increase in the us and that's
men who have sex with other men.
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And then there is the population who
live with HIV and are immunosuppressed.
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And so as you add up all of these
populations, including those who are
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pregnant or who don't have access
to good prenatal care or infants
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who are born outside of the hospital
and did not get infant screening,
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now we're just starting encompass
pretty much the entire population.
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So your, threshold for testing should be
exceptionally low for everyone really.
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T.R. Eckler: I, I would tell you
our protocol in-house right now is
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to screen all of our psychiatric
patients that come in for both
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thyroid dysfunction and syphilis.
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And I think at first I'd just
never seen syphilis, so I was like,
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oh, I'm not sure we really need
to be doing this for everybody.
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But I've seen enough
positives come of that process
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Sam: Hmm.
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T.R. Eckler: that I'm realizing
how much more it's starting to
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become a bigger and bigger problem.
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Sam: Yeah.
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All right.
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Well, let's talk about
what causes syphilis.
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So syphilis is caused
by Treponema pallidum.
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It's a spirochete, it's a bacterium
and it's found only in humans.
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We are the reservoir for this
bacterium, for this disease.
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So we can't blame this on anything else.
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It basically lives and thrives off of
us, and it has no expressed surface
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based proteins, which is if you're
into the molecular biology of diseases,
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these are the things that allow us to,
you know, make antibodies and attack
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diseases early, and maybe even make
it an ideal vaccine for a disease.
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It doesn't display any of those.
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And that allows it to slip into
the central nervous system pretty
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easily, which unfortunately is
going to be one of those, phases
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we're gonna talk about here soon.
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And so it's a nasty little bug.
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It's transmitted through contact.
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That can be oral, vaginal, anal,
or skin to skin from lesions.
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And it can be from
mother to fetus in utero.
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And so that basically covers all
gamut of types of transmissions
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for pretty much any disease.
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Uh, It's not respiratory.
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And it can't be transmitted
through surfaces.
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So as long as you're wearing
appropriate PPE and gloves, you are
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protected as a healthcare provider.
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Interestingly, it has been shown,
at least there are some cases of
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it being transmitted through blood
transfusions and through dialysis.
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And so that's just another method
that the disease can be passed on.
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And unfortunately, previous infection
doesn't give you any kind of immunity.
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And if anything, becoming reinfected
patients are less likely to be
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symptomatic, so it just makes it
even more challenging if you're
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dealing with a repeat infection.
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T.R. Eckler: I'm trying to understand how
to read these titers is a really important
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thing to look at, and it's worth exploring
as we talk about this because you're gonna
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see more of these patients that have been
treated before and have been positive,
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and now you need to interpret whether
this is a new positive or an old positive.
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Sam: Yes.
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Yes.
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And if there's not a protocol in your
department, then hey, pull out this
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article, find those clinical pathways
and make that your department protocol.
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'cause it's already spelled
out by the authors very nicely
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here as a step-by-step process.
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Okay, so syphilis occurs.
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Really in, in multiple stages, there's the
primary syphilis, which is when they first
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get infected, it's somewhere around three
to six weeks after the initial infection,
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and they have a painless skin lesion.
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It's classically described as the
chancre, which is supposed to be
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initially this papule that then becomes
ulcerated and then resolves by itself.
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Unfortunately.
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It's painless.
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And so unless the patient happens
to see it, they're not gonna know.
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And if it's in an area where they don't
usually look because it's sexually
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transmitted, then they're gonna be
completely unaware this thing is present.
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And we as emergency clinicians
might have the opportunity to
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stumble upon it completely by
accident during an examination.
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So if you see this thing and it's
inconsistent with what you're looking
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for, then you just have to have a
really low threshold for saying, oh.
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You know, maybe we should get you tested.
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But that appears somewhere around three
to six weeks after initial infection.
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And just like any other disease
process, there's the classic lesion
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and then there's what can also occur.
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And if their patient has HIV or a
very high spirochete load, they can
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get multiple lesions, not just one.
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And they can be atypical looking So.
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It can be difficult to make
the diagnosis, but there is a
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good picture in the article.
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I encourage you to go take
a look at that, figure one.
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And that one's actually intraoral, so
it's a good picture to go take a peek at.
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Secondary syphilis is the rash and
it's associated with a prodrome fever,
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headache, fatigue, and lymph adenopathy.
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And the most common rash that you
see is this red, red, brown, kind
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of flat and scaly and diffuse, and
again, it's classically described
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as being on the hands and feet.
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So you see a rash on the hands
and the feet, you're thinking
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like hand, foot, mouth.
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You should also think syphilis because
this is one of those diseases that is
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supposed to classically present this way.
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But unfortunately it can also
be more diffused so it's not
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isolated to the hands and feet.
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It can be generalized all over their body.
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Sometimes the lesions can be vesicular,
sometimes they can be pustular.
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And these are considered like
the less typical presentations,
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but they're possible and they can
occur about four to eight weeks.
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After the appearance of the chancre,
so the chancre was coming three
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to six weeks after the infection.
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Now four to eight weeks later,
we've got secondary syphilis with
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the prodrome of those symptoms.
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And if it's untreated, it's going
to resolve on its own within a few
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weeks to a month and then go away.
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And now we're in that problem stage where
the patient once again has no awareness
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of the disease that they're carrying.
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And that brings us to tertiary syphilis.
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This is the late stage infection,
and this can occur as late as 50
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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.