Ryan Grabeic, FNP-C
The essence of providing healthcare to a community lies in the ability to expand beyond the confines of our usual practice, reaching those areas of care inadequately addressed. As in any aspect of society, the stigma surrounding topics such as sexual health has historically limited access to care, as well as created challenges in societal education and prevention.
Among those illnesses, syphilis is an STI that when addressed in a timely manner, is effectively treated. When allowed to persist, the infection may prove to have significant morbidity, or in extreme cases, be fatal. This case will explore a relatable experience in the Urgent Care setting, examine the presenting factors, testing modalities, and lastly differential diagnosis. The paper will also address the recommended evidence-based diagnostic pathways available to the Urgent Care medicine provider, as well as outline patient considerations, recommended follow-up, and treatment for primary through tertiary syphilis in an UC setting. Lastly, discourse will conclude with recognition of syphilis as it pertains to the Upstate New York region and overall epidemiologic trends.
Case Study: A 47-year-old Caucasian, heterosexual male presents to a UCC in an urban region of Upstate NY with the chief complaint of a genital lesion and concern for herpes. He admits the lesion has been present for roughly two weeks. He states he has had two sexual partners over the last six months with whom he engaged in penile-vaginal unprotected intercourse. He denies oral or rectal intercourse. The partners were both females, he denies any intercourse with men. He describes the lesion as located near the tip of his penis. He notes the lesion is nontender. He denies any aggravating or remitting factors and states no treatment modalities have been attempted. This is the first time he has sought care for this condition. He denies any known STI history. The patient denies any fever, fatigue, body aches/chills, nausea, vomiting, diarrhea, dysuria, penile discharge, urinary frequency/urgency, abdominal pain, flank pain, dizziness/lightheadedness, changes in motor/sensory function, or other associated rashes.
The patient has a past medical history of bipolar disorder with manic episodes, as well as alcoholism. He reported noncompliance with current prescriptions and was unable to list his bipolar medication. He is currently homeless and has a 30-pack-year smoking history. He denied any illicit drug use. There were no known allergies and no surgical history. There was no known family history. Vital signs: 136/78, T-98.4, 80, 16, 99% on room air. On exam, there is a notable firm, round, 1cm in diameter, painless lesion to the dorsal aspect of the shaft of the penis, just proximal to the glans. The lesion is a notable ulceration with a firm raised and sharp border and is flesh colored. There is no active discharge or drainage, edema, warmth, extending erythema, pruritis, or vesicular changes.
The differential diagnoses include primary syphilis, genital herpes, HPV, chancroid, donovanosis, lymphogranuloma venereum, and furuncle (Hicks & Clement, 2021). Primary syphilis is most likely because the lesion is a single non-vesicular, well-demarcated painless ulceration, and has been present for roughly two-weeks.
Syphilis is entirely treatable when identified early and appropriate therapy is initiated. The causative infective agent in syphilis is the bacterium Treponema pallidum. As is in many infectious processes, early recognition remains a key factor in prognosis (Resnick et al., 2014). Testing for primary syphilis in the UC setting requires a venipuncture and send out laboratory testing. Testing modalities require an initial non-treponemal and subsequent confirmatory treponemal test if the non-treponemal test is positive. The current recommended tests for initial syphilis testing are the rapid plasma reagin (RPR) and the venereal disease research laboratory (VDRL) tests. These tests carry a sensitivity of 92.7% and 72.5% respectively. The tests both identify the presence of IgG and IgM to a protein found in the T.pallidum bacterium (Godfrey et al., 2020). If either the RPR or VDRL are positive, it is imperative to perform treponemal testing to confirm. The FTA-abs test carries the highest sensitivity of 98.2% and specificity of near-100%. Given the rise of syphilis infection rates, point of care (POC) testing for syphilis is currently under development, with certain products showing sensitivity and specificity rates of 75-90% and 92-100% (Godfrey et al., 2020).
When a positive diagnosis is made in the UC setting, beginning prompt treatment and referring to either primary care or community health department clinics for follow-up is of the utmost importance (Brown & Frank, 2003). In most states, a positive test is health-department-reportable for contact tracing and monitoring of treatment.
Syphilis treatment is highly effective with little to no resistance rates documented to date (Hicks & Clement, 2021). First-line treatment is 2.4 million units IM of benzathine Penicillin G IM for all primary and secondary cases of syphilis (Godfrey et al., 2020). In the patient discussed above who had no allergies, this first line treatment should be initiated promptly. The patient should be referred to the local community health clinic for follow-up. Although repeat testing is not always recommended, in cases of high-risk individuals such as the case discussed, repeat testing for treatment efficacy versus reinfection is supported. Additionally, cases of syphilis carry a high risk of co-infection with other STIs such as HIV, HPV, HSV, as well as gonorrhea and chlamydia. Patients should be tested for these other common STDs within the same visit if possible. Follow-up in a primary setting aims at both treatment management and prevention in these populations (Hicks & Clement, 2021).
Patients who have tertiary or late syphilis (excluding neurosyphilis), or who are immunocompromised with HIV should be treated with penicillin G benzathine 2.4 million units IM weekly for three weeks (Hicks & Clement, 2021). For those patients with documented anaphylaxis to penicillin, doxycycline 100mg PO BID for two-weeks is recommended. Azithromycin and ceftriaxone are currently not supported by literature as second-line treatment (Hicks & Clement, 2021). If neurosyphilis is suspected, the patient should be referred to the ED after consultation with an attending. These individuals often require lumbar puncture to determine the presence of T. pallidum in CSF. If positive, these individuals require penicillin G IV every four hours or IM daily with probenecid given orally for 10-14 days. If penicillin anaphylaxis exists, these individuals must undergo desensitization and continue penicillin treatment under controlled in-patient settings (Hicks & Clement, 2021).
Syphilis in the United States today is nearing epidemic proportions. Infection rates have steadily risen since the year 2000, which saw only 56 cases in New York State. The latest reported data representing 2019, showed 7,240 cases state-wide. (NYS DOH, 2019). For the UC provider, there is a criticality in understanding infection and prevalence rates in the communities for which one practices.
The UC setting is one of opportunity and importance. With overcrowding of emergency departments, limited access to care, and severe shortage of primary care providers, UC fills a vital void. The UC provider should always cast a wide differential and implore astute history and physical exam skill sets to limit the gaps that might exist. UC providers help to close these gaps in community health and can prove a life-or-death difference in the lives of their patients.