Syphilis — Rapid | Doctor’s Passport

Synopsis

Recognise stage-specific and neurological syphilis, interpret treponemal and non-treponemal tests together, deliver penicillin-based therapy and confirm serological response with partner management.

Primary syphilis usually causes a painless indurated ulcer with regional lymphadenopathy, but chancres can be painful, multiple or hidden.
Secondary syphilis causes a generalized rash often involving palms and soles, mucous patches, condylomata lata, lymphadenopathy and systemic symptoms.
Latent syphilis has reactive serology without clinical signs; timing determines whether early or late-latent treatment is needed.
Use a treponemal screening and confirmation test plus a quantitative RPR or VDRL titre to assess activity and follow response.
Direct PCR from an early lesion can support diagnosis before serology becomes reactive where locally available.
Treat primary, secondary and early latent syphilis with benzathine benzylpenicillin 2.4 million units intramuscularly once.
Treat late latent or unknown-duration syphilis with benzathine benzylpenicillin 2.4 million units intramuscularly weekly for three doses.
Penicillin is required in pregnancy; allergy needs specialist desensitisation rather than a fetal-risk substitute.

Key red flags

Any visual symptom with reactive syphilis serology is ocular syphilis until urgent ophthalmic assessment proves otherwise.

Sudden hearing loss, tinnitus or vertigo can represent otosyphilis and needs same-day specialist review.

Headache, meningism, cranial neuropathy, cognitive change, tabetic symptoms or young stroke prompts neurosyphilis assessment.

Syphilis in pregnancy can transmit at any stage and requires immediate maternity and sexual-health coordination.

A high-risk chancre with initially negative serology requires lesion testing and repeat serology rather than reassurance.

Failure of the non-treponemal titre to fall appropriately raises reinfection, treatment failure, wrong stage or neurological involvement.

Early neurosyphilis

Meningitis, cranial neuropathy, ocular inflammation, hearing disturbance or meningovascular stroke may occur during early infection.

Late neurological disease

Cognitive and personality change, sensory ataxia, lightning pains, bladder dysfunction and abnormal pupils suggest parenchymal involvement.

Congenital-risk setting

Any reactive result during pregnancy requires urgent confirmation, staging and treatment because maternal symptoms do not predict fetal risk.

Investigation priorities

Treponemal screening immunoassayFirst step

Detect antibodies indicating present or previous T pallidum infection.

Management branches

TESTConfirm and stage infection

Screening serology, a compatible lesion, rash or partner notification raises syphilis probability.

Take treponemal and quantitative non-treponemal tests and lesion PCR where available before treatment.
Document previous syphilis results and treatment, symptoms, neurological or sensory features, pregnancy and timing of possible acquisition.
Examine skin, mouth, anogenital sites, lymph nodes, neurological system and eyes or hearing according to symptoms.
Classify primary, secondary, early latent, late latent, tertiary or neuro-ocular disease with sexual-health specialists.

Key medicines

Benzathine benzylpenicillin for early syphilisGive 2.4 million units intramuscularly once, usually divided between two gluteal sites according to product and local administration protocol.Confirm the long-acting benzathine product, never give intravenously, clarify anaphylaxis history and counsel about Jarisch–Herxheimer symptoms.

Benzathine benzylpenicillin for late latent syphilisGive 2.4 million units intramuscularly once weekly for three doses for late latent or unknown-duration infection.Record every date, seek advice after a missed interval, and use specialist pregnancy management because complete penicillin treatment is essential.

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