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Syphilis in HIV-infected patients
Last reviewed: 18.10.2021
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Diagnostic notes
In HIV-infected patients with syphilis, unusual serological reactions are observed. Most reports indicate titres higher than expected, but false negative results and a delay in the manifestation of sero-reactivity have also been reported. Nevertheless, both treponemal and non-treponemal serology tests for syphilis are interpreted in all HIV-infected patients with syphilis as well as in non-infected HIV.
If a clinical examination confirms the presence of syphilis, and serological tests produce negative or questionable results, alternative tests such as a biopsy of the affected area, a study in a dark field of vision, or a UIF with a material from the affected tissue may be useful in these cases.
In HIV-infected patients, differential diagnosis of diseases of the nervous system should consider the possibility of neurosyphilis.
Treatment
Published case reports and expert opinions indicate that HIV-infected patients with early syphilis have an increased risk of developing neurological complications and treatment failure with conventional regimens. The level of risk, although it is not precisely established, is not too large. There is no evidence that any other treatment regimen was more effective in preventing the development of neurosyphilis than the regimens recommended for patients without HIV infection. Significant importance is the follow-up after the end of treatment.
Primary and secondary syphilis in HIV-infected patients
Treatment
It is recommended the same treatment with benzathine penicillin G, 2.4 million units IM / m, as for HIV-negative patients. Some experts recommend additional treatment, for example, multiple doses of benzathine penicillin G, as in late syphilis, or other antibiotics in addition to a dose of 2.4 million units per minute of benzathine penicillin G.
Other observations on patient management
CSF abnormalities are often detected both among asymptomatic HIV-infected patients, in the absence of syphilis, and in uninfected HIV patients with primary or secondary syphilis. However, it is not known what the pro-growth significance of these deviations is in HIV-infected patients with primary or secondary syphilis. Most HIV-infected patients respond appropriately to the commonly recommended treatment with penicillin; however, some experts recommend that CSF be examined before therapy starts and, accordingly, changes in the treatment regimen are made.
Follow-up
Clinical-serological control is performed in HIV-infected patients after 1 month, and then 2,3, 6, 9 and 12 months after the end of treatment. Some experts recommend that after the completion of therapy (for example, after 6 months) a re-examination of CSF.
In HIV-infected patients, if treatment is ineffective, a CSF study is necessary; they should be treated again in the same way as patients without HIV infection. It is also necessary to study CSF and re-treatment of patients with primary and secondary syphilis, whose antibody titers in non-treponemal tests do not decrease 4-fold within 3 months after the end of treatment. With normal CSF, most experts recommend re-treatment of benzathine with penicillin G, 7.2 million units (3 weekly doses, 2.4 million units each).
Special Remarks
Allergy to penicillin
HIV-infected patients with primary or secondary syphilis who are allergic to penicillin should be treated as well as non-infected with HIV.
Hidden syphilis in HIV-infected patients
Diagnostic notes
HIV-infected patients with early latent syphilis should be treated and treated as HIV-negative patients with primary and secondary syphilis.
In HIV-infected patients with either latent latent syphilis or syphilis of unknown duration, CSF should be examined before treatment.
Treatment
HIV-infected patients with late latent syphilis or syphilis of unknown duration and normal CSF can be treated with benzathine penicillin G, 7.2 million units (3 weekly doses of 2.4 million units per week). Patients who have CSF results consistent with the picture of neurosyphilis should be treated and treated according to the scheme recommended for neurosyphilis.
Follow-up
Clinical and serological control is performed after 6,12,18 and 24 months after completion of treatment. If during this period of time clinical symptoms develop or titres of non-treponemal tests increase 4-fold, a re-examination of CSF and appropriate treatment should be carried out. If between the 12th and 24th month the titre of non-treponemal tests decreased less than 4-fold, repeat the CSF study and prescribe the appropriate treatment.
Special Remarks
Allergy to penicillin
HIV-infected patients should be treated with penicillin at all stages of syphilis. To confirm the allergy to penicillin, skin tests can be used (see Management of patients with penicillin allergy). Patients can be desensitized, and then treated with penicillin.