Combatting the syphilis epidemic 

My phone rang early in the morning. I was surprised to hear the voice of an old friend from medical school on the other line. While we kept in touch regularly, it usually didn’t occur so early in the morning. I was worried that something horrible must have happened.  

“I’ve been working in the ED tonight caring for a man with syphilis,” they said in a rushed and tired voice. “But he also has these headaches, and I just can’t tell if they’re related or not. We’re getting slammed down here and I won’t hear back from ID for a few hours. Should I discuss a lumbar puncture with him? Or is it safe for him to go home?”  

Diagnosing and treating syphilis is confusing and complicated, fraught with a paucity of data despite over a century of experience with the spirochete Treponema pallidum. My friend was caring for a patient with neurosyphilis, which isn’t as rare as you might think.  

Today, rates of syphilis and other sexually transmitted infections (STIs) are skyrocketing. In 2021, there was a 74% increase in cases of syphilis as compared to in 2017. Even more alarmingly, there was a 200% explosion of cases of congenital syphilis within this same time frame. Last November, the Centers for Disease Control and Prevention published a Morbidity and Mortality Weekly Report, outlining how 90% of congenital syphilis cases were preventable except for lack of timely testing and treatment. Furthermore, this syphilis epidemic is disproportionately affecting the most marginalized and vulnerable patients.  

Amid this surge in cases, we’re increasingly finding ourselves faced with syphilitic conundrums. For example, syphilis diagnostics have been largely unchanged for the past century. Even with diagnostic algorithms and thoughtfully worded guidelines, the RPR still finds ways to confuse me.

Compounding this, access to testing is limited. There are at least eight states in the U.S. where syphilis testing in pregnancy is not mandated. In regard to treatment, while intramuscular benzathine penicillin remains the stalwart of effective therapy for primary, secondary, and latent syphilis, there’s a severe shortage of the drug. Clinicians are being forced to consider other antibiotics which lack data supporting their use. For example, there are no currently recommended alternatives to benzathine penicillin therapy in pregnancy (for example, if someone is allergic to penicillin).  

The conversations that we  have with our patients regarding syphilis are therefore crucial. Here are a few things to keep in mind:

1. We must know our patients as people; people who have sex. We must evoke the sacred trust of the patient-physician relationship to openly discuss our patient’s sexual health. Without understanding someone’s sexual health, we’re in the dark when it comes to effectively screening, staging, and treating syphilis.  

2. Because the symptoms of  “the great imitator” are so ubiquitous, clinicians may find it helpful to discuss manifestations of syphilis with patients as they are examining them. Subtle physical examination findings (such as epitrochlear lymphadenopathy, alopecia, oral ulcers, or the “classic” rash involving palms and soles), or elucidating a history of such, can be crucial in correctly staging the infection.  

3. Utilize vetted flowcharts in conversations with patients to illustrate how devastating syphilis can be. We must empower our patients to receive excellent treatment and follow-up at the time of diagnosis to prevent them from suffering poor long-term outcomes.  

4. Utilize ID and public health experts/colleagues.

It is paramount that we engage our patients in these conversations to combat the syphilis epidemic.

This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.