Synopsis
Use lesion, rash, exposure and prior-treatment information to stage possible syphilis, choose the correct penicillin course, protect pregnancy and neuro-ocular function, and close the loop with titre and partner follow-up.
- Build the stage from today’s examination, earlier symptoms, contact dates, previous serology and documented treatment; the laboratory result alone cannot date acquisition.
- Swab or sample a compatible active lesion for direct detection where available and send a treponemal screen, a second treponemal assay and a quantitative RPR or VDRL before treatment when this causes no unsafe delay.
- A chancre may be hidden in the cervix, rectum or mouth, and secondary disease may present through rash, mucous lesions, alopecia, nodes, hepatitis or sensory symptoms; examine every anatomical site suggested by the history.
Key red flags
Treat new visual loss, photophobia or ocular inflammation with compatible syphilis serology as a same-day ophthalmic and sexual-health problem.
Escalate sudden hearing loss, new tinnitus or vestibular symptoms because otic disease may leave permanent deficit despite few other syphilis signs.
Ask directly about headache, meningism, cranial-nerve symptoms, cognitive or personality change, sensory ataxia and young stroke before assigning a simple stage.
Link any syphilis diagnosis in pregnancy immediately to maternity care: clinical stage and maternal wellbeing do not reliably express fetal risk.
Do not close an ulcer episode after a single early negative antibody test when lesion appearance, contact history or timing keeps pre-test probability high.
A sustained fourfold RPR or VDRL rise after therapy starts a new assessment for fresh exposure, incomplete therapy, an incorrect original stage or neurological involvement.
Uveitis, altered vision, auditory or vestibular change, meningitic symptoms, cranial neuropathy, stroke in a younger adult or cognitive decline overrides routine staging and needs urgent organ-specific assessment.
A reactive test or credible infectious contact in pregnancy requires prompt confirmation, stage-appropriate penicillin and a communicated fetal and neonatal pathway, even when the patient feels well.
Investigation priorities
Establish whether the immune pattern supports T. pallidum exposure while reducing the chance of relying on one assay.
Management branches
A lesion, rash, contact notification or screening result raises the possibility of syphilis.
- Take direct lesion testing when possible, two-method treponemal testing and a quantitative RPR or VDRL before therapy if this is safe.
- Reconstruct symptom, exposure and testing dates and verify every previous treatment rather than accepting “treated before” without a usable record.