Consultant Genitourinary Medicine Objectives Describe the common and even the not so common presentations of early syphilis Recall the indications for testing for mycoplasma genitalium and why we dont recommend routine screening ID: 1042630
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1. Primary Care STI updateDr Hannah Loftus (she/her)Consultant Genitourinary Medicine
2. ObjectivesDescribe the common (and even the not so common) presentations of early syphilis.Recall the indications for testing for mycoplasma genitalium and why we don’t recommend routine screening.Describe the most efficient way for Primary Care clinicians to refer a patient to Sexual Health Sheffield.
3. Case 1-May 202027 year old man5 day history of yellow discharge from his urethra and pain passing urineNo testicular pain or swellingLast sex- can’t quite remember, “definitely before lockdown”Approximately 6 female partners in the past 6 months.
4. Diagnosis?Photo removed
5. ManagementDue to skeleton service we had no in-house microscopySwab taken for gonorrhoea cultureUrine sent for chlamydia and gonorrhoea NAATBlood sent for HIV and syphilisTreated for presumed gonorrhoea with stat dose of 1g IM ceftriaxone
6. Results-4 days later due to weekendCT/GC NAAT negativeHIV and syphilis negativeCalled patient-not very happy as he feels no better!Diagnosis?
7. Treated as presumed mycoplasma genitalium1st line for non-complicated mycoplasma genitalium- doxycycline 100mg BD 7 days followed by azithromycin 1g day 1, 500mg days 2 and 3.Covered for trichomonas vaginalis with metronidazole 400mg BD 5 daysHis symptoms resolved
8. Mycoplasma genitaliumFirst isolated in 1981Mollicutes class. Smallest known self-replicating bacteriumNo cell wall-not visible by gram stainDiseases associated with M. genitalium are thought largely to be due to host immune response, it has been shown to be directly toxic to cells causing cilial damage in human fallopian tubes.
9. Mycoplasma genitaliumPrevalence rates in general population range from 1-2%. Amongst sexual health clinic attendees, 4-38%.Found in genital tract and rectum. Carriage in oropharynx is rare
10. Indications for testing (symptoms)Test in patients presenting withNon-gonococcal urethritisPersistent/recurrent urethritisPeople with signs and symptoms suggestive of pelvic inflammatory diseasePeople with signs or symptoms of muco-purulent cervicitis, particularly post coital bleeding
11. Indications for testing (symptoms)Only test in the following cases if people re-present with persistent symptoms despite first line treatment:Epididymitis/epididymo-orchitisSexually acquired proctitisSexually acquired reactive arthritisIntermenstrual bleeding-once other diagnoses are excluded E.G. contraceptive cause/chlamydia
12. Indications for testing (risk factors)Test current sexual partners of persons infected with mycoplasma genitalium.
13. Testing (not currently readily available from primary care)Targeted based on symptoms and contactsNo evidence that screening asymptomatic individuals will be of benefit and is likely to do harm at a population levelPeople with a penis: first void urinePeople with a vagina: vulvovaginal swab (Aptima swab)Ideally all positive specimens should be tested for macrolide resistance-mediating mutations.
14. TreatmentNon-complicated infection:1st line: doxycycline 100mg BD 7 days followed by azithromycin 1g on day 1, 500mg on days 2 and 3.2nd line: moxifloxacin 400mg OD 7 daysComplicated infection:Moxifloxacin 400mg OD 14 daysMacrolide resistance globally: 30-100 % (UK approx 40%)Moxifloxacin resistance increasing in Asia-PacificTest of cure at 5 weeks (and definitely no earlier than 3 weeks)
15. GonorrhoeaRates are high. 50% increase since 2021There have been cases of ceftriaxone resistant gonorrhoea infection.
16. GonorrhoeaIdeally refer all suspected and confirmed cases to a sexual health clinicCultureLow threshold for pharyngeal samplingTreatment with ceftriaxone unless known to be sensitive to ciprofloxacinIf patient declines to attend sexual health, use cefixime 400mg plus azithromycin 2g statPartner notificationTest of cure
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18. Case 231 year old man3 week history of abdominal pain2 week history of rash to abdomenSaw GP:CRP 15, FBC NAD, U&Es NADPrescribed omeprazoleOn further questioning: swollen nodes in neck for 2 weeks and 3 painless sores to penis
19. Case 2PMH: Genital herpes diagnosed 9 years ago. Most recent recurrence 1 year agoDHx: PrEP-event based dosingAlcohol: 20 units/week on averageNo recreational drugsLSI: 1.5 week ago with RMP of 3 years-receptive anal and oral. No condomPSP: 3/12 ago. CMP. Insertive and receptive anal and oral. No condom10 partners in past 12 months
20. ExaminationBilateral cervical lymphadenopathy1.5cmx1cm shallow ulcer to underside of tongueMacular rash to trunk. Macules to soles of both feet. Not affecting palmsEnlarged right groin nodeMild tenderness RUQ and epigastric region. No organomegalyScaly erythematous areas to scrotum2 shiny erythematous lesions to glans penis-not ulcerated.Small peri-anal fissure
21. Diagnosis?Photo removed
22. ManagementNothing amenable to sample for dark ground microscopyTests sent for syphilis, HIV and hepatitis C (already vaccinated against hepatitis A/B and HPV)Tests sent for triple site chlamydia and gonorrhoeaU&Es, LFTs, FBC sent in view of the abdominal painTreated empirically for secondary syphilis with stat dose of benzathine penicillin 2.4MU IM
23. Results later that dayALP 933, bilrubin 24, ALT 350, albumin 45Platelets 292U&Es normalExtended LFTs added-GGT 584, AST 211HIV, Hep C Ab negative. Hep B sAb> 100.Hep A Ab detectedRepeated the following dayALP 954, ALT 293, AST 138, GGT 520, bili 27, clotting normalFelt more unwell-worsening of rash and “flu-like”. Likely Jarisch-Herxheimer reaction.
24. Confirmed diagnosis-secondary syphilisTreponemal antibody detected, TPPA positive, RPR 32, IgM detected.Hep C RNA not detected. CMV IgM not detected, EBV IgM not detected.Day 0Day 1Day 3Day 114 months Bilirubin24271386ALP93395487937675AST2111381592925ALT3502932745620GGT58452047217417
25. The liver and syphilisHepatic involvement with early syphilis likely under-reported/detected.Typically cholestatic but can be hepatocellular or mixed.Disproportionately high ALP and GGT levels with slightly raised or normal transaminases and bilirubin are common.Can cause peri-cholangiolar inflammation, hepatocyte necrosis, non-caseating granulomas.Resolves quickly post penicillin treatment
26. Number of infectious syphilis* diagnoses by gender: England, 2013 to 2022UK Health Security Agency: 2022 STI slide set (version 1.0, published 6 June 2023)26* The number of infectious syphilis diagnoses includes primary, secondary and early latent diagnoses.‡ Data reported in 2020 and 2021 is notably lower than previous years due to the reconfiguration of SHSs during the national response to the COVID-19 pandemic
27. Staging of untreated syphilisEarly (infectious). Up to 2 years from acquisitionPrimarySecondaryEarly latentLate (non-infectious). Beyond 2 years from acquistion.Late latentGummatousNeurological Cardiovascular
28. Primary syphilisPrimary chancre - 95% genital skin, also nipples, mouth, rectumIncubation ‘9-90 days’ - usually 21-35 daysDusky macule - papule- indurated clean based non-tender ulcer. 50% solitaryRegional nodes 1-2 weeks after after chancreUntreated - heals without scarring after 4-8 weeks.If serology negative at baseline repeat when ulcer has been present for at least 2 weeks
29. Photos removed
30. What proportion of people will develop signs of secondary syphilis?10%25%50%66%80%
31. Secondary syphilisOnset usually 4-10 weeks after infection but can be longer.Untreated 25% of people will develop signs of secondary syphilis.Primary chancre may be present concurrently (30%)May have no history of primary chancre
32. Secondary syphilisRash (70%)Constitutional symptoms Mucous membrane lesions (30%)Generalised lymphadenopathy (50-60%)Patchy alopeciaHoarsenessBone pain (lytic lesions)HepatitisGlomerulonephritis/ nephrotic syndromeDeafnessIritis, uveitis, interstitial keratitis, retinal involvement, optic neuropathy. MeningitisCranial nerve palsies (CN 8)Condylomata lataArthralgias
33. Recent cases4 cases of ophthalmic syphilis in 2023Patient with a knee effusion-also had lymphadenopathy (referred to lymphoma pathway), hair loss, ophthalmic involvement.3 cases of otosyphilis in past 1 year.35 year old man with widespread lytic lesions including the skull, mild hepatitis, kidney lesions, skin and tonsillar lesions. Under investigation for ?histiocytosis.Elderly man with rectal mass and bleeding. Presumed cancerMan in 20s with rectal mass and bleeding. Presumed cancer3 cases of patients with suspected oral cancer
34. Syphilis - untreated65% No clinical sequelae15% Late benign gummatous 2 -40 years after exposure10% Neurosyphilis 2-30 years after exposure General paresis 10-15 years, tabes dorsalis 15-35 years10% Cardiovascular 20-30 years after exposure
35. How to contact Sexual Health Sheffield.We do not have a walk in serviceHowever we do operate a Dr/nurse practitioner call back system for patients who are triaged as urgent by the call centreFor routine/semi-urgent advice or referrals email sth.sexualhealthadmin@nhs.netFor immediate advice bleep the GUM Dr via switchboard (held by a consultant, specialty dr or senior SpR).We are closed from 12.30pm on Fridays (but you can try the bleep, it may get answered).
36. SummarySTI rates are highMycoplasma genitalium is definitely causing pathology, but successful treatment can be difficult.Resistant gonorrhoea is a concern-please refer to sexual health for suspected/ confirmed cases.Think syphilis!
37. ObjectivesDescribe the common (and even the not so common) presentations of early syphilis.Recall the indications for testing for mycoplasma genitalium and why we don’t recommend routine screening.Describe the most efficient way for Primary Care clinicians to refer a patient to Sexual Health Sheffield.
38. ReferencesGuidelines | British Association for Sexual Health and HIV (bashh.org)Sexually transmitted infections (STIs): annual data tables - GOV.UK (www.gov.uk)Dourra M, Mussad S, Capatina-Rata A. An unsual case of syphilis with abdominal pain. Cureus. 2021 Aug;13(8): e16806Huang et al. Syphilitic hepatitis: a case report and review of the literature. BMC gastroenterology 19, Article number: 191 (2019)
39. QuestionsHannah.loftus1@nhs.netGUM bleep. Mon &Thu 9-7pm, Tue & Wed 9-5pm, Fri 9-2pm (often still contactable 2pm-5pm)