Academy Exchange

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

Hi Barbara:

There is no need for treatment at this point. Once the titer reaches 1:16, the current criteria have been met. The increase from 1:16 to 1:33 represents only a slight rise and is considered clinically insignificant. To suspect reinfection or treatment failure, you would need at least a twofold increase, such as from 1:16 to 1:64. Even in such cases, if there are doubts, it is advisable to repeat the test in two weeks to confirm any potential failure.

Penicillin treatment for syphilis has an extremely low failure rate, so most cases of increased titers are due to reinfection rather than treatment failure. In this case, I wouldn't be concerned, and I recommend continuing follow-up in six months.

Let me know if I can help you out.

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

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Barbara Hart
Lawrence KS
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I would keep a close eye on this patient with repeat RPR with reflex to TP every 3 months or per your followup lab schedule for his HIV care. Because RPR results finalized by the Medical Lab Tech is based on their visual interpetation of the regeant reaction. So results can vary depending on who is interpeting the result. Pending any contraindication, I would get this patient on doxyPeP. I had a patient with a technical treatment response to PCN with a RPR that remained low over 6 month 1:16 from 1:256 who ended up being sent to the ED when he presented to the clinic for a routine follow-up and complained of headache and visual changes. Diagnosed with neurosyphilis. RPR never went over 1:16. 

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Martel S. Warden, MHA, MSN, APRN
Family Nurse Practitioner
Christian Community Health Center
Chicago, IL 60628
------------------------------

Original Message:
Sent: 10-10-2024 16:54
From: Barbara Hart
Subject: Syphilis titers

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

------------------------------
Barbara Hart
Lawrence KS
------------------------------

I would keep a close eye on this patient with repeat RPR with reflex to TP every 3 months or per your followup lab schedule for his HIV care. Because RPR results finalized by the Medical Lab Tech is based on their visual interpetation of the regeant reaction. So results can vary depending on who is interpeting the result. Pending any contraindication, I would get this patient on doxyPeP. I had a patient with a technical treatment response to PCN with a RPR that remained low over 6 month 1:16 from 1:256 who ended up being sent to the ED when he presented to the clinic for a routine follow-up and complained of headache and visual changes. Diagnosed with neurosyphilis. RPR never went over 1:16. 

------------------------------
Martel S. Warden, MHA, MSN, APRN
Family Nurse Practitioner
Christian Community Health Center
Chicago, IL 60628

Original Message:
Sent: 10-10-2024 16:54
From: Barbara Hart
Subject: Syphilis titers

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

------------------------------
Barbara Hart
Lawrence KS
------------------------------

Without new neurologic, ophthalmic, or otic signs or symptoms, the patient does not need re-treatment.  If the titer were to rise fourfold from the seemingly stable level of 1:32, then he would need treatment with a single BPG (provided he had been coming for regular f/u and it had not been 12 or more months since the prior RPR).

There are some noteworthy points about this case. First, the longer a syphilis infection remains untreated, generally the longer it will take the titer to fall or serorevert. Second, if the neurosyphilis was not his first syphilis infection, he would be less likely to return to a non-reactive RPR.  Similarly, HIV infected patients generally have a slower decline in RPR following treatment than do HIV uninfected patients.  

You state that the patient had skin lesions concerning for gummas, which are found in tertiary syphilis that's been present for a long time, sometimes decades.  Consider also malignant syphilis, or mucous patches, both of which are manifestations of early syphilis (technically secondary, and both more common in HIV infected persons).  The point being that neurosyphilis can occur early, within a matter of weeks after the infection.  It's not just a late manifestation.

The patient does not need a reflex to a treponema antibody with subsequent RPR's because treponema tests usually remain positive for life following the first infection.

As much as possible, the patient should have his follow-up RPRs done in the same lab. Most likely the 1:256 you report was done in a hospital lab and the subsequent outpatient ones may have been done in a different lab. No matter, just try to have the subsequent ones done in the same outpatient lab. RPR titers can vary from one lab to the next, even a fourfold difference.

Some experts may recommend a LP if the RPR does not fall below 1:32 (see C. Mara).  Absent clinical signs or symptoms our group has generally not done this, especially when there is such good documentation of initial diagnosis and adequate treatment.

I agree with the strong recommendation for doxycycline PEP in addition to careful followup, but with regard to my point above, I'd be interested if others might suggest a LP prior to starting doxycycline PEP.

Robert Bolan, MD

Los Angeles LGBT Center

I would keep a close eye on this patient with repeat RPR with reflex to TP every 3 months or per your followup lab schedule for his HIV care. Because RPR results finalized by the Medical Lab Tech is based on their visual interpetation of the regeant reaction. So results can vary depending on who is interpeting the result. Pending any contraindication, I would get this patient on doxyPeP. I had a patient with a technical treatment response to PCN with a RPR that remained low over 6 month 1:16 from 1:256 who ended up being sent to the ED when he presented to the clinic for a routine follow-up and complained of headache and visual changes. Diagnosed with neurosyphilis. RPR never went over 1:16. 

------------------------------
Martel S. Warden, MHA, MSN, APRN
Family Nurse Practitioner
Christian Community Health Center
Chicago, IL 60628

Original Message:
Sent: 10-10-2024 16:54
From: Barbara Hart
Subject: Syphilis titers

Hello, I have a question regarding possibly serofast syphilis titers. I am still relatively new to the process of monitoring titers in the HIV positive patient. 

I have a fellow who was diagnosed with HIV/AIDS in 2022 when admitted for encephalopathy. RPR titer elevated at 1:256. He had LP with CSF noting features consistent with neurosyphilis. He was treated with IV pen G 4 mil units every 4 hours x 14 days. He had skin lesions concerning for gummas. 

His initial CD4 count was 70. Started on Biktarvy and Bactrim but had to switch to atovaquone due to rash with Bactrim. He has done well since that time and has not been sexually active since his diagnosis. CD4 is now 259, with variation around the 300 range.

Initial RPR titer of 1:256 declined over one year to 1:16, then went to 1:32, and has stayed at that level for the next year. Is this unusual? Is there other testing I should consider? Should he be retreated with Bicillin LA x 3? I am surprised it has not gone lower than this. I would be grateful for your advice. Thank you. 

------------------------------
Barbara Hart
Lawrence KS
------------------------------