Syphilis information for health professionals

Syphilis is a bacterial STI which if left untreated, can cause serious complications or death. There is currently an outbreak in the Perth metropolitan area. We recommend having a low threshold in testing for syphilis.

Syphilis presentation

50% of cases are asymptomatic

Test for syphilis in all patients presenting with a genital ulcer.

– Painless ulcer/chancre around genitals, anus, or mouth – Generalised rash, fever, malaise, headache – Enlarged lymph nodes – Neurological signs, cranial nerve palsies, ophthalmic signs, meningitis	Infectious <2 years	Commonly called primary, secondary and early latent syphilis
Skin lesions (gummas), cardiovascular or neurological complications	Non-infectious >2 years	Commonly called late latent and tertiary syphilis

Common diagnoses that present like syphilis

Syphilis may imitate	Presentation
Herpes simplex 1, 2	Multiple superficial oral and genital ulcers
Candidiasis	Redness, itching, discomfort in affected area.
Chancroid	Painful sores on the genitalia
Urethritis	Discharge from the penis, stinging or burning when passing urine. Itching, tingling irritation inside of the penis
Cystitis	Abnormal urine colour, urinary frequency or increased urgency. Flank pain, back pain, pressure in lower back or pelvis. Nausea, vomiting, fever, chills.
Other STIs	Chlamydia, Gonorrhoea and Trichomonas vaginalis
HIV	Acute illness with fever, lymphadenopathy, rash, fatigue and myalgia.
Dermatitis	Itchy inflammatory conditions, epidermal changes
Guttate Psoriasis	Inflammatory skin condition with widespread small plaques
Pityriasis rosea	Pink, flaky, oval-shaped rash followed by similar, smaller oval red patches mainly on the trunk. Viral rash may be accompanied with headache, fatigue, fever and nausea.
Viral exanthem	Measles, mumps, chicken pox, cytomegalovirus, rubella. Findings may include fever and rash.
Mononucleosis	Low-grade fever, sore throat, white patches on tonsils and back of throat, weakness, fatigue, tender lymphadenopathy, petechial haemorrhage and skin rash.
Brain tumour	Findings may overlap with neurosyphilis including headache, seizures, visual changes and personality changes.
Other causes of seizures	Neurosyphilitic disease can present with seizures and must be differentiated from other causes of seizures
Other causes of stroke	Weakness, sensory loss, ataxia, cranial nerve damage.
Meningococcemia	Rash, petechiae, headache, confusion, stick neck, malaise, fever, altered mental state, nausea and vomiting.

Testing

Dry swab any ulcer. Ask for a GUMP PCR. (Genital ulcer multiplex PCR) This tests for herpes, syphilis, chancroid, donovanosis.
Blood test. Ask for syphilis serology

Patients being treated for primary and secondary syphilis should have a rapid plasma reagin test (RPR) repeated on the day treatment is commenced to provide an accurate baseline for monitoring treatment.

Pregnant and post-partum women should be tested for syphilis in accordance with WA Health recommendations.

Treatment

Penicillin is the drug of choice for treating syphilis as its effectiveness is well established and treponemes have not developed penicillin resistance.

There is little evidence for non-penicillin regimes which must be regarded as inferior. Assess for true penicillin allergy before seeking alternatives.

Refer here for treatment in pregnancy.

	Recommended	Alternative
Infectious	Benzathine Penicillin (Bicillin L-A) 2.4mu IMI Stat	Doxycycline 100mg PO BD 14 day course
Non-infectious	Benzathine Penicillin (Bicillin L-A) 2.4mu IMI weekly for 3 weeks	Doxycycline 100mg PO BD day course

Accessing Benzathine penicillin(Bicillin L-A)

Benzathine pencillin (Bicillin L-A) is now available through the Prescriber Bag scheme. As a GP you can order a box of Benzathine penicillin (Bicillin L-A) each month (i.e. 10 injections or 5 treatments per month) for free so that you can supply to your patients. For more information visit https://www.pbs.gov.au/browse/doctorsbag

Patients may find it difficult to access Benzathine penicillin (Bicillin-LA) from a community pharmacy. In general, pharmacists will be able to order Bicillin-LA for a patient and it be ready for collection the following day. However, greater delays may be experienced for patients in regional or remote areas.

If a patient is unable to access the medication from a community pharmacy and you don’t have any on your person, the below options are available to you.

The patient can be referred to a public sexual health clinic for further management and treatment.

Royal Perth Sexual Health Clinic, Level 4, Ainslie House, Royal Perth Hospital, 48 Murray St, Perth WA 6000. Phone: (08) 9224 2178 and Fax: (08) 9224 3557
South Terrace Sexual Health Clinic, A Block, Fremantle Hospital, South Terrace, Fremantle WA 6160. Phone: (08) 9431 2149

You may contact Metropolitan Communicable Disease Control (MCDC) who can assist you in accessing a supply of Benzathine penicillin. Phone (08) 9222‑8588, or Email ContactMCDC@health.wa.gov.au