Episode 104
104: StAR: Neurosyphilis
This StAR episode features the CID State-of-the-Art Review on neurosyphilis.
Our guest star this episode is Dr. Matthew Hamill (Johns Hopkins University)
Journal article link: Hamill MM, Ghanem KG, Tuddenham S. State-of-the-Art Review: Neurosyphilis. Clin Infect Dis. 2024 May 15;78(5):e57-e68. doi: 10.1093/cid/ciad437. PMID: 37593890.
Journal companion article - Executive summary link: https://academic.oup.com/cid/article/78/5/1085/7672813
From Clinical Infectious Diseases
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Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hi
Sara Dong:everyone, welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics, and antimicrobial management.
Sara Dong:I'm Sara Dong, your host and a MedPeds ID doc.
Sara Dong:I am excited to introduce our guest today, Dr.
Sara Dong:Matthew Hamill.
Sara Dong:Matthew is a UK trained physician specializing in sexually transmitted infections.
Sara Dong:He is an assistant professor of medicine in the Division of I.
Sara Dong:D.
Sara Dong:at Johns Hopkins in Baltimore.
Sara Dong:He also serves as clinical chief for STI services at the Baltimore City Health Department.
Sara Dong:He provides patient care for people with HIV and other STIs as well as those at risk for infection.
Sara Dong:His research focuses on harnessing diagnostic development to improve HIV STI diagnosis, prevention, and linkage to care.
Sara Dong:Thanks for being here!
Matthew Hamill:Oh, my pleasure, Sara.
Matthew Hamill:Thank you for asking me.
Sara Dong:So before we chat about the article, I always ask, as everyone's favorite cultured podcast, we like to ask our guests to share a little piece of culture, really just something non medical that makes you happy.
Matthew Hamill:Yeah.
Matthew Hamill:There are several things that make me happy, but particularly at this time of year in the spring.
Matthew Hamill:I have this tiny, uh, postage stamp sized garden at the back of my house in Baltimore City, and just being out there and watching the flowers come out and the birds start to collect, um, some nesting materials.
Matthew Hamill:That gives me a huge amount of pleasure at this time of year.
Matthew Hamill:So probably like my number one thing right now when I have time is just to go and stand in the garden for a few minutes at the end of the day.
Sara Dong:I love it.
Sara Dong:Yeah.
Sara Dong:It is the perfect time of year.
Sara Dong:I just went and saw a ton of tulips and daffodils last weekend.
Sara Dong:Just nice to be outside.
Matthew Hamill:It's really nice.
Matthew Hamill:Yeah.
Matthew Hamill:It's kind of hopeful and optimistic and, I can never really remember where I planted things.
Matthew Hamill:So it's like each spring is a, is an adventure.
Sara Dong:Yes.
Sara Dong:Well, we are super grateful to have you here for the latest STAR episode.
Sara Dong:So these are focusing on the state of the art reviews and you and your coauthors worked on one related to neurosyphilis.
Sara Dong:So we actually have a couple of clinical scenarios that we'll chat about, but I wanted to pause first to just allow you to have a chance to give a quick introduction to the topic and or things that sort of came up as you, you all were crafting this.
Matthew Hamill:In general terms, when we think about syphilis, there are several things that occupy my mind a lot of the time as I spend a fair amount of my professional life either treating patients with syphilis or providing advice to clinical colleagues.
Matthew Hamill:I think a couple of things that are just worth pointing out are the inexorable increases in syphilis diagnosis in the United States.
Matthew Hamill:So we're looking at all stage syphilis.
Matthew Hamill:There's been an almost 80 percent increase in all stage syphilis diagnosis in the, in the last five years.
Matthew Hamill:And the element of syphilis that is the most heart wrenching in some respects is congenital syphilis, where we've seen 180 percent increase in congenital syphilis diagnosis in the last half decade and over 30 percent just in the previous year.
Matthew Hamill:And whilst that's not directly related to neurological syphilis as we're spending most of the time talking about, I think for context that both of those facts are really important.
Matthew Hamill:And sometimes I talk with clinical colleagues outside of infectious diseases and they'll say, really syphilis still a thing in 2024?
Matthew Hamill:Um, and I think there are some perceptions that syphilis is an infection assigned to history, but unfortunately, that's absolutely not the case.
Matthew Hamill:In terms of neurosyphilis or neurological syphilis, I'll use the two terms interchangeably.
Matthew Hamill:The question about the epidemiology of, uh, of neurological syphilis is a great one.
Matthew Hamill:I can hand wave a little bit and speculate, but I think we really don't collect nationally representative high quality data on neurosyphilis diagnoses.
Matthew Hamill:So I think what we can try to do is to say that as overall syphilis diagnoses are increasing, we expect the rate of neurological complications to increase in tandem with that.
Matthew Hamill:But, um, unfortunately, I'm not able to, uh, look at surveillance data and say, these are the, in inverted commas, "real" increases in neurosyphilis.
Sara Dong:Um, all right, so I have a couple of clinical calls from your colleagues, so we'll start with our first one.
Matthew Hamill:Great.
Sara Dong:You get a consult call for a patient.
Sara Dong:This is a 50 year old male.
Sara Dong:He has a history of hypertension, diabetes, and coronary artery disease who came in with behavioral changes.
Sara Dong:The family tells you and the other clinician that he has been really irritable.
Sara Dong:He's actually been almost hostile over the past couple of months, which is really out of character for him.
Sara Dong:He has had some headaches and just challenges sleeping.
Sara Dong:He more recently has developed periods of confusion and disorientation, uh, and the family thinks that he actually is probably having some memory loss, although they're having a hard time summarizing that for you.
Sara Dong:And today though, he was brought in more urgently because of an episode of speech difficulty.
Sara Dong:On his labs, we know that his routine labs are normal.
Sara Dong:They sent HIV and hepatitis screens, which are negative, but we already know that he has a positive RPR from that initial blood work.
Sara Dong:Um, this case is obviously not meant to be a mystery.
Sara Dong:Our, our listeners kind of already know we're talking about neurosyphilis.
Sara Dong:Uh, so before we confirm our suspected diagnosis of neurosyphilis, I was hoping you could provide a refresher on the natural history and really the major clinical syndromes associated with symptomatic neurosyphilis because it's not just sort of one representative clinical presentation.
Matthew Hamill:Yeah, absolutely right.
Matthew Hamill:And I completely agree with that high level summary that, um, is there are, of course, textbooks, examples of particular, uh, neurological syndromes associated with neurosyphilis, but there's overlap.
Matthew Hamill:I think that's one of the important points to make, is that there are overlap between some of the different neurological manifestations.
Matthew Hamill:Some of the old natural history studies, particularly in the pre antibiotic era, are quite different to the clinical presentations that we see now, where antimicrobial use is so common, people will have received doxycycline for a skin and soft tissue infection or a Z Pak for a upper respiratory tract infection.
Matthew Hamill:So people will have been exposed often to antimicrobials that will have some activity against Treponema pallidum, the bacteria that causes syphilis.
Matthew Hamill:So I think that probably in part explains why the natural history of neurological syphilis is somewhat different compared to historical accounts.
Matthew Hamill:But with all things syphilis, the way that I
Matthew Hamill:conceptualize it is to, and there's a danger in doing this, but what I do particularly when I'm trying to think about it and, and provide, teaching and training is to try and break it down into different buckets based on clinical stages.
Matthew Hamill:And for neurological syphilis, we can apply this same rationale.
Matthew Hamill:So we can think about some of the early neurological manifestations, and then we can think of late neurological manifestations.
Matthew Hamill:A point that I would make that many people either have forgotten or never knew is that people can have neurological involvement at any stage of infection, even before they develop a primary syphilitic chancre.
Matthew Hamill:So if you look hard, you can see evidence of T.pallidum in the CSF of people who haven't yet developed their primary lesions.
Matthew Hamill:You can see it in people with primary disease, with secondary syphilis, etc.
Matthew Hamill:But in terms of some of the early manifestations, and we think about this within the first year of infection, they often present with a a quite typical picture of meningitis, where there will be, you know, headache, there may be cranial nerve involvement.
Matthew Hamill:Sometimes people will present with what looks like a stroke, and occasionally people will have more extensive basilar involvement of the meninges, and cranial nerve pathologies can progress quite, quite rapidly.
Matthew Hamill:So sometimes early neurological syphilis can be very similar to other forms of meningitis.
Matthew Hamill:And then as time progresses in somebody who hasn't received treatment, then you can sort of break the late neurological manifestations into three buckets.
Matthew Hamill:So the meningovascular, parenchymatous, and then those that we see with gummatous disease.
Matthew Hamill:So the meningovascular manifestations are similar to the ones that I've just talked about where people will present with a stroke.
Matthew Hamill:They may present with spinal cord disease where there's been vascular involvement of the vessels to the spinal cord.
Matthew Hamill:And this can happen anything from 5 to 15 years after treatment.
Matthew Hamill:And then the parenchymatous disease, again that's broken into two, but that's typically sometime after the meningovascular disease, so up to 20 years after infection.
Matthew Hamill:And the parenchymatous disease we can think of the type that causes a picture very similar to the one that you've described where people will have memory loss, personality change, problems with communication with their families, and then the tabetic form where the, uh, where the parenchymatous involvement is at the level of the spinal cord.
Matthew Hamill:And that's where people will present with posterior columns, uh, signs and symptoms.
Matthew Hamill:And then the final is the gummatous disease, which can occur as early as two years after infection and as late as 40 years after infection.
Matthew Hamill:And this is where somebody will present with features of a space occupying lesion.
Matthew Hamill:And then just to add a couple of additional thoughts, is that ocular and otic syphilis, so syphilis affecting the eye and the ear.
Matthew Hamill:Again, that can occur at any stage of syphilis infection.
Matthew Hamill:And embryologically, those three compartments, so CNS, eye, ear, are slightly distinct, but clinically we group them together when we think about treatment in particular.
Sara Dong:And that's such a good reminder and just to say again, like, like you've been pointing out that neurosyphilis as we think of it can really occur at any stage and I made it pretty obvious for this patient that they would benefit from an LP and we're going to come back to the results of that.
Sara Dong:We all agree on proceeding to LP in patients who have neurologic symptoms, but oftentimes the question of who needs a CSF examination is a bit more challenging than that and probably has led to many phone calls to you and other experts.
Sara Dong:And I actually was hoping before we go back to our patient case that we talk about those scenarios.
Sara Dong:When are scenarios that an asymptomatic patient with serologic evidence of syphilis should get a lumbar puncture?
Matthew Hamill:Thank you for asking that question, Sara.
Matthew Hamill:And you're right, you have a very good idea of what my weeks look like when I'm discussing, um, discussing management of syphilis with my expert colleagues
Matthew Hamill:. There are some guidelines that, that help us and I think the CDC guidelines are really very helpful in that respect.
Matthew Hamill:But as I mentioned before, often with things relating to syphilis, black and white is quite rare and we're dealing in shades of grey and, often calls for understanding the nuance of the particular clinical context and that's when it's so important that we engage in shared decision making with our patients.
Matthew Hamill:When we are straightforward about what we know and we're also straightforward about the uncertainties in terms of diagnostic.
Matthew Hamill:How certain are we in our, in our diagnosis and how much evidence is there to support a particular management approach?
Matthew Hamill:So all of that said, I think the people with neurological signs and symptoms of syphilis, absolutely, lumbar puncture is indicated and really helpful.
Matthew Hamill:The exception is in people who have only ocular or otic manifestations.
Matthew Hamill:For those individuals, a lumbar puncture or CSF examination is not mandated for the simple reason is that it will be normal in about 40 percent of people with ocular disease and up to 90 percent with otic syphilis.
Matthew Hamill:In terms of when we should consider lumbar puncture outside of the context of people with symptoms, then there are a couple of scenarios where it's wise to really consider it carefully.
Matthew Hamill:And the first of those is when somebody has a sustained, and I stress the sustained, increase in RPR or VDRL titer.
Matthew Hamill:I'll use RPR just for efficiency sake.
Matthew Hamill:If someone has a sustained increase in their RPR of fourfold or more, and by sustained, I mean that the laboratory test is repeated at least two weeks afterwards, and that increase has remained the same.
Matthew Hamill:And the individual patient has had no opportunity for reinfection.
Matthew Hamill:So for instance, you meet with someone, they've had treatment for their syphilis , and they have a sustained fourfold increase in titer, and you take a careful sexual history, and it's very clear that this person has not been re exposed.
Matthew Hamill:So that's one situation where we should consider a CSF examination.
Matthew Hamill:And the reason for that is that they may have undiagnosed asymptomatic neurosyphilis, and that's what's driving this increase in RPR.
Matthew Hamill:And the other scenario is in individuals who fail to see a fourfold decrease in their RPR titer after stage specific treatment and after the requisite amount of time has elapsed.
Matthew Hamill:So that's another group where one can have a discussion around the pros and cons of CSF examination.
Matthew Hamill:And then the final group are those who have evidence of tertiary disease, so whether that's gummatous disease or evidence of cardiovascular syphilis.
Sara Dong:And I'll point out for figure two, there's a nice flowchart for this, but also if they are checking out the CDC STI guidelines also find these.
Sara Dong:So thank you for walking through that.
Sara Dong:Back to our patient, you learn that the CSF on the LP is clear.
Sara Dong:There was a lymphocytic pleocytosis.
Sara Dong:The white blood cells are 50 with a lymphocyte percentage of 80%.
Sara Dong:Total protein was 50 milligrams per deciliter.
Sara Dong:A CSF VDRL is pending.
Sara Dong:And so while we're waiting on the results, there's a learner working with you and is hoping that you can give a quick overview of lab testing for syphilis, specifically of CSF testing.
Sara Dong:You know, does the CSF profile seem typical?
Sara Dong:What are the best CSF testing options for diagnosing neurosyphilis?
Matthew Hamill:Yeah, thank you.
Matthew Hamill:So, the information that we have so far, so we have the clinical scenario, we have a sense of a pretest probability of, of this being, uh, neurological syphilis, and the, the results that we have available so far are consistent with neurosyphilis, particularly with that raised, uh, white cell count.
Matthew Hamill:There's no question that that is an increased, uh, white cell count, and particularly with the lymphocytic predominance, I think you said it was 80 percent lymphocytes.
Matthew Hamill:So that would be my trigger to initiate treatment and not waiting for any other laboratory results to come through.
Matthew Hamill:I think the CSF protein is probably the least helpful marker that we, that we routinely request when we're investigating neurological syphilis.
Matthew Hamill:And the reason that I say that is that it can be increased in many other conditions.
Matthew Hamill:It can be normal in neurosyphilis.
Matthew Hamill:So whilst I don't dismiss the CSF protein, it's probably the marker that I pay least attention to.
Matthew Hamill:And if it's an isolated finding, then again, I really need to go back and look at the history, look at the exam findings, look at the imaging, and really, I think, long and hard about whether I'm going to make a suggestion that will commit this individual to 10 to 14 days of intravenous treatment.
Matthew Hamill:But the white count, I think it's a great marker.
Matthew Hamill:It's really quite sensitive.
Matthew Hamill:And a CSF white count of 50, even in the setting of somebody who's living with HIV, again, that it's high enough to trigger action in terms of treatment.
Matthew Hamill:So, for people living with HIV, we know that their, that their white count may be higher than somebody who's, uh, who's not living with HIV, so you can increase the sensitivity of a neurosyphilis diagnosis by considering a white count up to 20 as, uh, potentially normal in, in somebody with, uh, particularly with untreated HIV infection.
Matthew Hamill:And then we're waiting for the, for the rest of the tests to come back, and depending on where you work in the world will dictate the suite of serological tests that are available to you.
Matthew Hamill:In the US, we use the CSF VDRL and that is a very, very useful test.
Matthew Hamill:If it's positive, then I think you can feel very confident that you, you've clinched your diagnosis.
Matthew Hamill:What I would say is that the person doing the LP needs to look at the CSF and make sure that it's not blood stained.
Matthew Hamill:If it is, then one can't really interpret the VDRL because there may be spillover from, from the blood compartment.
Matthew Hamill:But if you have clear CSF and you have a positive VDRL, then I think that that is a anchor of our neurosyphilis diagnosis.
Matthew Hamill:In other places in the world, such as in the UK, where I'm from and worked for many years, then we use a CSF RPR instead of a CSF VDRL.
Matthew Hamill:It probably doesn't perform as well as a VDRL, but it will give you comparable results.
Matthew Hamill:In the US, we don't look at TPPA, for example, uh, in the CSF, which is done in other settings.
Matthew Hamill:The other serological test that we occasionally use is the FTA.
Matthew Hamill:If you have a patient who has a history that's consistent with neurosyphilis and you have a negative VDRL, and in some situations, you can ask the laboratory to send off, unless they do it in house, it's usually a send out test, um, to do it, to do an FTA, and that can help you to make a diagnosis in less clear cut cases.
Matthew Hamill:So we talked about protein, we talked about white counts, we've talked about some of the serological markers, there are PCR assays that are available for, for diagnosing syphilis, and they can be incredibly helpful, particularly when people have lesions, so primary chancres and in more secondary lesions, and a PCR is really great, is very sensitive and specific.
Matthew Hamill:In CSF, it doesn't perform as well.
Matthew Hamill:It's not a test that most people in the United States have access to, and I think the performance characteristics are much, much less well established compared with syphilis, where somebody actually has a lesion that you can swab.
Matthew Hamill:And the Holy Grail, one of the Holy Grails of syphilology is trying to find a biomarker that provides a reliable, robust, independent marker to say, yes, this is neurosyphilis or this is definitely not neurosyphilis.
Matthew Hamill:And as you can probably tell by my preamble, um, we don't have a biomarker currently, apart from the ones that I've described, that can currently be used to aid us in diagnosing or excluding neurological syphilis.
Matthew Hamill:There are biomarkers that have showed promise, such as CXCL13 in the CSF, and there are many, many biomarkers that have been looked at, but I think the current state of play is that really we don't have anything that replaces the CSF VDRL at the present time.
Sara Dong:We'll say this patient's CSF VDRL was positive, confirming what we already thought for our diagnosis.
Sara Dong:The patient is placed on first line therapy for neurosyphilis, so aqueous penicillin G is on a continuous infusion.
Sara Dong:Based on guidance, the plan, we talked about 10 vs 14 days, and the plan is to do a 10 day course.
Sara Dong:And the patient actually had a listed allergy to penicillin on the chart, which fortunately, your awesome ID fellow actually de labeled, as it was not a true allergy that needed desensitization.
Sara Dong:But your inquisitive medical student on the team asks some follow up questions.
Sara Dong:"I thought I saw that you could use ceftriaxone or doxycycline, like what if that patient had a true allergy and that, gee, that sure seems simpler than penicillin".
Matthew Hamill:It's great having astute fellows and medical students, um, isn't it, who, um, who appropriately ask challenging questions.
Matthew Hamill:So to try and unpack that a little bit and take those, uh, alternative treatments one by one, and there are some data, but there are not many data supporting the use of ceftriaxone in somebody who is unable or unwilling to use IV penicillin.
Matthew Hamill:So the CDC definitely sanctions the use of uh, ceftriaxone at the dose of one or two grams daily, either by an intramuscular or intravenous route.
Matthew Hamill:And many of us use that and there is quite a lot of clinical experience about using ceftriaxone in the treatment of neurosyphilis.
Matthew Hamill:The, the trial data just really aren't there.
Matthew Hamill:I mean, there are some small studies and there are some comparative studies, but the evidence base around ceftriaxone is quite limited.
Matthew Hamill:I would add at this point that in, in pregnancy, then the only treatment that is recommended by the CDC is, is penicillin.
Matthew Hamill:So if the question was being asked in the context of pregnancy, then I would not, uh, based on current evidence, recommend treatment with anything other than penicillin as you described.
Matthew Hamill:So I think ceftriaxone has promise, you know, it is something that's used.
Matthew Hamill:It can be given on an outpatient basis.
Matthew Hamill:If somebody, if you can find a clinical service that would give you your intramuscular injection at a weekend.
Matthew Hamill:So there are some advantages practically for patients to receiving that treatment modality.
Matthew Hamill:In terms of doxycycline, that is not something that is currently considered appropriate in a U.
Matthew Hamill:S.
Matthew Hamill:setting.
Matthew Hamill:So I would reply to the medical student learner that that is something that I would not use in this setting.
Matthew Hamill:In the UK, for example, then doxycycline at a relatively high dose, so 200 milligrams twice daily for 28 days, is an alternative agent for the treatment of neurological syphilis, but the data upon which that recommendation is based is quite thin, but we have decades of experience in the UK of using doxycycline as treatment for neurological syphilis.
Sara Dong:Thank you for walking through those.
Sara Dong:And fortunately, our patient is improving, is doing better.
Sara Dong:And I actually wanted to talk about one other clinical scenario.
Sara Dong:So say you have a clinician who's calling you from a primary care center.
Sara Dong:They have a patient in their practice with a new diagnosis of HIV and on those initial evaluation labs has a positive RPR.
Sara Dong:So they want to know whether this patient who is asymptomatic needs to be referred for LP, um, and a CSF evaluation.
Matthew Hamill:Are you able to provide me with, I mean, I kind of have an answer for you, but I'm going to drag it out.
Matthew Hamill:I'm going to drag it out a little bit for the sake of suspense.
Matthew Hamill:Um, um, do you have any other information on this person who's newly diagnosed with HIV, like their CD4 count, for example?
Sara Dong:Um, let's say that their CD4 count's like 400.
Matthew Hamill:Okay.
Matthew Hamill:And the RPR titer?
Sara Dong:Uh, one to, oh, I have to do the math in my head.
Sara Dong:Oh, I did, I didn't a make up an RPR titer.
Matthew Hamill:So what about one in 128?
Sara Dong:Let's do that.
Matthew Hamill:Yeah.
Matthew Hamill:Okay.
Matthew Hamill:Okay.
Matthew Hamill:In this context, generally speaking, so you have somebody newly diagnosed with HIV, they have evidence of syphilis, presumably they have a positive treponemal test and then as well to provide serological confirmation.
Matthew Hamill:So this person definitely has syphilis, the usual rules apply that you would look at their previous history of syphilis diagnosis and treatment, you'd want to know what their previous RPR was if they had one, and then you would want to stage the syphilis, and that is really important because staging allows us to be confident in terms of the treatment recommendations that we will, that we will
Matthew Hamill:make, but in this context, someone with a decent CD4 count with a relatively high RPR who is otherwise asymptomatic, I most certainly would not rush to suggest a CSF examination in in this context.
Matthew Hamill:The CDC guidelines, again, are really helpful here.
Matthew Hamill:They make it clear that in most scenarios that people are staged with syphilis and treated in the same way regardless of their HIV status.
Matthew Hamill:I mean, of course, there are some exceptions.
Matthew Hamill:If you have somebody, let's say, who had advanced HIV disease and a high RPR, something equal to or greater than 1 to 32, where follow up might be tricky, let's say this is somebody who is an inpatient where they received this new dual diagnosis and you're worried that they're not going to be able to follow up as an outpatient for whatever
Matthew Hamill:reason, then in that scenario, then I would be more willing to consider a CSF exam to be able to exclude neurosyphilis in this patient where follow up might be uncertain.
Matthew Hamill:But generally speaking, this person would be treated in the same way as somebody with the same presentation who was not living with HIV.
Matthew Hamill:As I'm sure, will be the case, this person will be started as soon as possible on antiretroviral therapy and receive stage appropriate syphilis treatment if they haven't already been adequately treated.
Matthew Hamill:. Sara Dong: Thank you for humoring my my bonus scenario.
Matthew Hamill:No, not at all.
Matthew Hamill:You know, it's a really important one because things have changed a lot in HIV management over the last 30 years and things that we may have reflexively done in the past, um, the weight of evidence has really reassured us, that in the vast majority of cases, that HIV per se needn't alter the way that we approach management of a patient with syphilis.
Sara Dong:Are there new strategies, either that you think maybe folks aren't familiar with yet, or that are on the horizon for thinking about prevention of syphilis.
Sara Dong:And this can be more sort of broadly, um, particularly for, you know, trainees and listeners to keep an eye out for.
Sara Dong:And I think one question I would love to hear your thoughts is how you think use of DoxyPEP may impact neurosyphilis.
Sara Dong:I know there's not going to be a super clear answer, but I'd love to hear insights that you might have.
Matthew Hamill:Yeah.
Matthew Hamill:I mean, I certainly have a lot to say about it.
Matthew Hamill:How well informed it is remains to be seen.
Matthew Hamill:Um, but, um, I think it's a really important question and I think that the data that I very briefly described at the beginning of our conversation about these really alarming increases in all stage syphilis and in congenital syphilis tells me that our current approaches are failing.
Matthew Hamill:And we can't keep doing the same thing and hope that magically this problem will improve.
Matthew Hamill:What I really think is that we have some tools that we know are really useful.
Matthew Hamill:So things like partner notification to try and contact sexual partners of people who have potentially been exposed to syphilis to have those people come in for evaluation and treatment.
Matthew Hamill:We know that that pays dividends.
Matthew Hamill:The problem is that there has historically been underinvestment in the services that underpin those partner notification approaches using disease intervention specialist colleagues.
Matthew Hamill:So, I don't want to abandon the things that we already have that work just because we've been doing them for a long time, but I want to recognize that in order to do those things well, then it requires investment, training and political will.
Matthew Hamill:There are also some great opportunities for us in the social media era.
Matthew Hamill:For example, disclosure of sexually transmitted infections can be very difficult for some people.
Matthew Hamill:For some, the idea of having a face to face conversation or a telephone call with a sex partner to say, I've been diagnosed with syphilis, you really need to go and get tested and evaluated.
Matthew Hamill:Those conversations can be really difficult, but there are now online tools.
Matthew Hamill:There are websites and apps where you can enter in anonymously the cell phone or email of a, of a sexual contact who will then receive an anonymous notification to say, you may have been exposed to syphilis.
Matthew Hamill:Please follow up with your healthcare provider.
Matthew Hamill:So those are some of the things that we should continue to invest in.
Matthew Hamill:Regular testing, so mathematical models have shown that one of the most efficient ways of reducing the burden of untreated syphilis, undiagnosed syphilis, is by more regular testing in people who have increased risk for syphilis infection.
Matthew Hamill:I think it's fair to say that even though we have clear guidelines about, uh, testing for syphilis, that most people aren't being tested with the frequency that they should be tested.
Matthew Hamill:So that's a whole long winded way of saying, don't throw the baby out with the bathwater, and then it's kind of gearing me up to talk about doxycycline post exposure prophylaxis, which I love, um, I see where there are huge opportunities for preventing bacterial sexually transmitted infections including syphilis.
Matthew Hamill:And you can't get neurosyphilis if you don't have syphilis.
Matthew Hamill:So it sounds as if I'm being facetious and I'm not.
Matthew Hamill:It really is acknowledging the potential benefits of the doxycycline post exposure prophylaxis.
Matthew Hamill:So this is something that has been on the horizon since about 2018 with the first study that came out of France.
Matthew Hamill:And since then, there have been more studies that have demonstrated in different ways, but have demonstrated the efficacy of 200 milligrams of doxycycline given ideally within 24, but up to 72 hours after condomless sex.
Matthew Hamill:And the efficacy is, there's been, depending on the study that you look at, is around a 60 to 70 percent reduction in in bacterial STIs.
Matthew Hamill:And it seems that some of the data that are emerging out of conferences in 2024, such as the CROI conference, suggest that doxycycline PEP is most advantageous in prevention of chlamydia and syphilis and maybe less advantageous in the prevention of gonorrhea infection.
Matthew Hamill:So doxyPEP is something that is really very easy as a provider to provide to patients, DoxyPep is a really great way of providing patients with autonomy so that they're in control of the prevention strategies that they may choose to use in the same way that HIV pre exposure prophylaxis and post exposure prophylaxis, again,
Matthew Hamill:puts the autonomy in the hands of the patients and that's something that I encourage in all of my clinical consultations in order that people feel empowered.
Matthew Hamill:They feel like they're making a decision about their own sexual health and well being and I think that doxyPEP is a really great tool to add to that panoply of prevention interventions.
Matthew Hamill:It is certainly not a panacea.
Matthew Hamill:It's not a cure all.
Matthew Hamill:There's worries about antimicrobial resistance both in sexually transmitted infections as well as in other important organisms such as Staph aureus.
Matthew Hamill:There's concerns about the effect on the microbiome, for example, and what that might mean.
Matthew Hamill:And then a question that you asked is, how might this affect our diagnostic certainty around neurosyphilis?
Matthew Hamill:Is that right?
Matthew Hamill:Is that the question?
Sara Dong:Yeah.
Sara Dong:Well, really just any, either diagnosis or you kind of alluding to people, people's questions about resistance.
Matthew Hamill:Yeah.
Matthew Hamill:And I think we, the, the honest answer is we don't know yet.
Matthew Hamill:I mean, my worry is that, is that we'll see a blunting of, So, let's say somebody is taking DoxyPep, they acquire syphilis, DoxyPep may abrogate their clinical presentation so that they may not present in a way that they might have done without the DoxyPep, and it might blunt their RPR response.
Matthew Hamill:So, I think it It's possible that you see someone who looks like they've had an adequate serological response to treatment, but they might not have, um, and really the, the RPR is being pushed down by, uh, intermittent use of doxycycline.
Matthew Hamill:I mean, that's a real rabbit hole , can make one's headache just to think about it because there are all these counterfactuals to explore.
Matthew Hamill:But I do think that that is something that we need to pay attention to and just be really thoughtful about what intermittent exposure to doxycycline may have done to somebody's serological markers of syphilis.
Sara Dong:Yeah.
Sara Dong:Well, I thank you also just for talking in general.
Sara Dong:I realize we may not have actually talked or had a episode specifically talking about DoxyPep and what it is.
Sara Dong:And you sort of by default talked through that.
Sara Dong:So I thank you because, um, I think the take home on DoxyPep though is that this is incredible, cutting down diagnoses by 70 percent ish is pretty amazing.
Matthew Hamill:Yeah, I agree with you.
Matthew Hamill:It really is.
Matthew Hamill:It's one of the most exciting interventions that I've seen in 25 years of, of working within sexually transmitted infections.
Matthew Hamill:There were a couple of really important caveats.
Matthew Hamill:And so I would say that the populations in whom we have evidence of efficacy are limited.
Matthew Hamill:So we have evidence of efficacy in men who have sex with men and in transgender women.
Matthew Hamill:We don't have evidence of efficacy in cisgender women or in men who have sex with women only.
Matthew Hamill:There was a clinical trial in Kenya that looked at DoxyPep in cisgender women who are currently taking HIV PrEP, and that study did not show a reduction in incident bacterial STI.
Matthew Hamill:It's likely that that is, as with many things biomedical, it hinged on adherence to the intervention.
Matthew Hamill:Um, and certainly more studies are required in women and studies are also required in heterosexual men or men who have sex with, with women.
Matthew Hamill:That's a group where there's, to my knowledge, a complete absence of evidence to date.
Sara Dong:So we'll wrap up by just giving a moment, if there's, you know, a specific take home point that you want to make sure that we emphasize, or if there's any other additional facts or concepts that you think we missed that would be important for your trainees and other listeners to know about neurosyphilis.
Matthew Hamill:We covered quite a lot of ground.
Matthew Hamill:At least I've talked a lot.
Matthew Hamill:Those two things are, uh, mean the same thing.
Matthew Hamill:But to summarize, I would like to reinforce a couple of points.
Matthew Hamill:And the first is that syphilis is still with us.
Matthew Hamill:It's prevalent.
Matthew Hamill:It's increasing.
Matthew Hamill:That's number one.
Matthew Hamill:Number two is if neurosyphilis was an easy diagnostic category, we probably wouldn't be having this conversation.
Matthew Hamill:Um, so what I mean by that is ask if you're not sure, ask somebody who has maybe a little more experience.
Matthew Hamill:I certainly do that all of the time.
Matthew Hamill:I consult with with my peers and senior colleagues.
Matthew Hamill:So there's never a point that one has to feel masterful in terms of diagnosis and management of neurological syphilis.
Matthew Hamill:It's, it's often not straightforward.
Matthew Hamill:And I think consulting with peers is, is incredibly important and helpful.
Matthew Hamill:The other point that I would make is the history is really important when thinking about neurosyphilis.
Matthew Hamill:Often we have an expectation that if a patient has troublesome symptoms, that they will volunteer those symptoms.
Matthew Hamill:That isn't always the case.
Matthew Hamill:So I think if you're concerned that someone has neurosyphilis, then inquire specifically about changes in memory.
Matthew Hamill:If the individual is struggling to be able to provide you with that information, ask if you have permission to speak with a family member, because that corroborative history can be really helpful.
Matthew Hamill:People tend to tell you when they have visual changes, because it's so alarming.
Matthew Hamill:People may not tell you when they have mild tinnitus or hearing loss, So when, when you see somebody who with syphilis, please ask specifically whether they've noticed any change in their hearing or whether they've had new onset tinnitus, because that may be the only clue that the, that the individual actually has a neurological syphilis.
Matthew Hamill:I think that probably the take home, I think we need much more data.
Matthew Hamill:We need clinical trials directly comparing different treatment modalities for neurosyphilis.
Matthew Hamill:Do we really need 10 days of IV penicillin?
Matthew Hamill:Could we achieve the same goal with, with less?
Matthew Hamill:Um, I think there are many, many unanswered questions and ongoing research is going to help us to answer some of, some of those questions.
Matthew Hamill:And I'd really like to finish with two thank yous.
Matthew Hamill:The first is to my friends and colleagues, Sue Tuddenham and Khalil Ghanem, who are co authors on this neurosyphilis review.
Matthew Hamill:I couldn't ask for better colleagues than that pair.
Matthew Hamill:I say that pair in a sort of smiling way because
Matthew Hamill:they'll appreciate what I mean.
Matthew Hamill:They're, they're wonderful.
Matthew Hamill:You know, I learn all the time from them and, you know, this review was really a joint exercise between the three of us and so I want to both thank and acknowledge their kindness, support, expertise, sense of humor.
Matthew Hamill:I could go on, but won't.
Matthew Hamill:And then the, the final word really is thank you to all of the patients that I have had the privilege to work with over the last two and a half decades.
Matthew Hamill:I love my job.
Matthew Hamill:I love being a physician and I love learning from my patients and it's endlessly humbling in a really positive way.
Matthew Hamill:So that's how I'd like to finish thanking all of those people who have trusted me enough to allow me to be involved in their health care.
Sara Dong:Thanks for listening to this STAR episode.
Sara Dong:You can find the State of the Art Review Neurosyphilis from Clinical Infectious Diseases linked in the Consult Notes as well as the episode information.
Sara Dong:Please check out our website, febrilepodcast.
Sara Dong:com, where you'll find the Consult Notes, which are written supplements of the episodes with links to references.
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Sara Dong:Febrile is produced with support from the Infectious Diseases Society of America or IDSA.
Sara Dong:Please reach out if you have any suggestions for future shows or want to be more involved with Febrile.
Sara Dong:Thanks for listening, stay safe, and I'll see you next time.
