A 24-year-old woman is being evaluated for positive reactive plasma reagin (RPR) testing for syphilis as part of a routine prenatal workup. The current titer is 1:8. She feels well and has no complaints. Six months ago, she went to the hospital with fever and a diffuse rash following sexual activity with a new male partner. There she underwent testing that showed an RPR titer of 1:256. The Treponema pallidum particle agglutination assay was positive at that time. HIV testing was negative. The patient was treated for secondary syphilis with intramuscular penicillin G. Her symptoms resolved over the next week. Her partner also was treated appropriately for syphilis at that time; she has had no new sexual partners.
Complete examination, including genital and neurologic examination, is normal. Repeat HIV antibody testing is negative.
What is the best next step in management of this patient?

Question

A 24-year-old woman is being evaluated for positive reactive plasma reagin (RPR) testing for syphilis as part of a routine prenatal workup.  The current titer is 1:8.  She feels well and has no complaints.  Six months ago, she went to the hospital with fever and a diffuse rash following sexual activity with a new male partner.  There she underwent testing that showed an RPR titer of 1:256.  The Treponema pallidum particle agglutination assay was positive at that time.  HIV testing was negative.  The patient was treated for secondary syphilis with intramuscular penicillin G.  Her symptoms resolved over the next week.  Her partner also was treated appropriately for syphilis at that time; she has had no new sexual partners.
Complete examination, including genital and neurologic examination, is normal.  Repeat HIV antibody testing is negative.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient was diagnosed with secondary syphilis before pregnancy and was treated appropriately with a dose of penicillin G. Repeat nontreponemal serologic testing 6 months later showed a significantly decreased, but still positive, reactive plasma reagin (RPR). There are 3 possible reasons for persistently positive nontreponemal testing: Inadequate or inappropriate treatment (failure of RPR to fall 4-fold within 6-12 months of treatment)ReinfectionSerofast reaction Inadequate or inappropriate treatment (failure of RPR to fall 4-fold within 6-12 months of treatment) Reinfection Serofast reaction This patient's titer decreased by over 4-fold, making inadequate treatment unlikely. She has no new symptoms, her partner also was treated appropriately, and she has no new partners, so reinfection is unlikely. In some patients, a low (serofast) titer may remain positive indefinitely after the initial 4-fold decline. The most appropriate strategy is to repeat testing in 6 months to ensure that the titer is stable and not rising, which would suggest reinfection. 11ec193a_9863_619f_853d_55d921c2f295_MD0002_00 (Choice A) Intramuscular penicillin is the appropriate treatment for primary, secondary, or latent syphilis. However, this patient was adequately treated for secondary syphilis, experienced an appropriate fall in titers, and has no symptoms or history suggestive of a new infection. (Choices B and C) Intravenous penicillin is the treatment for neurosyphilis, which may explain inadequate treatment in some patients. A lumbar puncture is warranted to establish the diagnosis. However, this patient had no neurologic symptoms and the RPR titer decreased as anticipated. (Choice E) Repeating the specific treponemal test, such as a Treponemal pallidum particle agglutination or fluorescent treponemal antibody-absorption test, is not indicated as these antibodies usually remain positive for life following infection. Educational objective: In HIV-negative patients treated for syphilis, repeat nontreponemal testing should be performed at 6 and 12 months to document response. A serofast response should be considered in patients who have a 4-fold decrease in titers but a persistently positive, low-level titer despite treatment. __________ References: Syphilis: a reemerging infection. (http://www.ncbi.nlm.nih.gov/pubmed/22963062) Update on syphilis: resurgence of an old problem. (http://www.ncbi.nlm.nih.gov/pubmed/13129993)

A 24-Year-Old Woman Is Being Evaluated for Positive Reactive Plasma