Complications And Prognosis

A phenomenon known as the Jarisch-Herxheimer reaction is a known complication resulting from antibiotic treatment of syphilis, and patients should be informed before initiating therapy. This typically develops within the first few hours of treatment and presents with fever, tachycardia, mild hypotension, headache, myalgias, arthralgias, exacerbation of skin lesions, and sometimes obtundation. The reaction is self-limited, but tends to last 12 to 24 hours. It is more likely to occur in patients with secondary syphilis. The reaction may be more serious in pregnant women, who can enter early labor or develop fetal distress. Patients with neurosyphilis or cardiovascular syphilis may also experience more serious and sometimes life-threatening manifestations. The reaction is well managed with non-steroidal anti-inflammatory medications as well as prednisone.

It is also worthwhile to discuss the interaction between syphilis and HIV disease. Given that both are sexually transmitted and associated with at-risk sexual behaviors, coinfection is common. The two may interact and enhance transmission of each other. With concomitant HIV infection, syphilis tends to present more aggressively. There is a tendency for involvement of more organ systems, atypical rashes, and greater constitutional symptoms, as well as increased rate of progression to neurosyphilis. Treatment failure is also more frequent, likely relating to the underlying immunocompromised state. Serologic responses are often altered with HIV-coinfected patients, showing high antibody titers sometimes leading to false-positive surveillance testing after adequate treatment (7). Frequent, extended follow-up is critical in such coinfected patients.

When syphilis is treated early, the prognosis is excellent. Primary and secondary disease treated appropriately with penicillin G has shown an 89% to 95% cure rate with initial therapy (20). Of those who fail to improve, most will respond to a second treatment. Late syphilis typically can be halted from further progression, although existing neurologic and cardiovascular injury cannot be reversed. Scarring from prior destructive mucocutaneous lesions will also remain, to varying degrees. Due to T. pallidum's ability to access tissues that are less immune-accessible, such as the eye, ear, and CNS, infection may remain in these sites even after adequate treatment. However, this persistent, sequestered infection usually produces no manifestations unless the host is immunocompromised. Data regarding the otologic response to treatment are mixed, but the trend across studies suggests that approximately 15% to 35% will gain at least some improvement with a combination of antibiotic and steroid therapy (21). Some factors associated with better response to intervention include fluctuating hearing loss, symptoms less than five years in duration, and age less than 60 (22). Isolated vertigo or tinnitus also tends to respond well, although if secondary to endolymphatic hydrops, the outcome is less promising. If left untreated, otosyphilis tends to take a progressive course, generally resulting in complete hearing loss and persistent vestibular symptoms.

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