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Syphilis RPR titer is the same after 3 months since treatment. Why?
This has been my first time ever diagnosed with Syphilis and other than that I don't have any other health problems. I got tested back in October 2014 with all STDs lab results--including HIV--negative, except for my RPR with titer: 1:64--later on it was confirmed by FTA-ABS with negative spinal tap results (neurosyphilis ruled out). I was then referred to an (sexual) infectious disease doctor at a county public health here in California where I was treated with penicillin treatment. Since previously I was tested for STDs 1 1/2 years prior to this and I didn't show any symptoms (I still don't), they determined it was Late Latent Stage (they considered unknown stage). As a result, they treated me with 3 rounds of penicillin treatment (Bicillin LA, 2.4 for both butt cheeks each week for 3 weeks). They assured me that the Penicillin is very effective and I should not worry and should I come back 3 months after for a follow-up.
Fast forward 3 months later in which I have only had protected sex (always wearing condoms, including oral) with the same, current girlfriend, I just came back from my follow-up. Consistently, all other STD lab results including HIV came back negative, but my RPR titer is still at 1:64 (!). At first, I panicked and asked the unsure nurse who said it could be a reinfection. However, when the doctor came he determined that I did not need further Penicillin treatment at this point, explaining "the important thing is the titer is still the same and has not increased...different bodies react and heal differently". Concerned as I am still, I asked if 1:64 is high, but the doctor explained calmly, "it is a strong indication of Syphilis, but since you have received 3 rounds of Penicillin treatment I consider you treated". He ordered me to follow-up again in 3 months (at 6 months after my last treatment).
Understanding that that titer is not the level of the Treponema pallidum, here are my questions:
1) Why hasn't my titer gone down? Should I be concerned? It is normal that sometimes it takes longer (longer than 3 months after last treatment) for titer to start dropping?
2) Should I be concerned about the case of treatment failure or am I overanalyzing since it is still too early to determine at this point? If so, what are the alternatives?
3) As I am conflicted after reading medical articles online with doctors/medical professionals saying that same titer or lower should be considered okay vs. same titer or higher should be treated with more Penicillin, could you help explain about what is the actual guideline at 3 month follow-up?
Thank you very much in advance!
Hi msartistm, I am in the same situation. Mine also is down only 2 fold from 1:32 to 1:16 after treatment and then it's same at 1:16 after a year. Di you get the LP and would you mind updating what happened after?
I sent along this follow up and was abotu to get some additional info, things on your end seem to be going in the right direction and you have made the right moves so far.
Thanks for the follow-up! I'm very glad this fellow got the ID consultation. Tell him not to get freaked by online horror stories about spinal taps. If done by an experienced clinician, it's really not a big deal. I tell my patients the overall stress and discomfort are similar to the average visit to the dentist for a cavity: not fun, but really no big deal. And certainly trivial compared with the potential problems of neurosyphilis.
If NS if found, IM procaine penicillin indeed is an alternative to IV treatment. However, IV pen may actually be more convenient. The ID specialist may be able to set up home IV services, where they place an IV line and the patient gives himself the antibiotic at home, with no hosptialization except maybe the first day, for training. With the shots he would have to go the the doc's office once daily. And the shots are large and pretty uncomfortable.
Thanks for the follow-up! I'm very glad this fellow got the ID consultation. Tell him not to get freaked by online horror stories about spinal taps. If done by an experienced clinician, it's really not a big deal. I tell my patients the overall stress and discomfort are similar to the average visit to the dentist for a cavity: not fun, but really no big deal. And certainly trivial compared with the potential problems of neurosyphilis.
If NS if found, IM procaine penicillin indeed is an alternative to IV treatment. However, IV pen may actually be more convenient. The ID specialist may be able to set up home IV services, where they place an IV line and the patient gives himself the antibiotic at home, with no hosptialization except maybe the first day, for training. With the shots he would have to go the the doc's office once daily. And the shots are large and pretty uncomfortable.
Thanks so much for your help! Second opinion from a referral infectious disease doctor and a spinal tap are indeed something that I'm considering seriously. I'm dreading the spinal tap, but I have done research online and based on what others have gone through, it's not that bad after all--especially if given local anesthesia and the caffeinated drinks to increase the fluid level and replace what would be taken. Basically, I'm just worried about complications of fluid leaking, headache, etc...but I'm racing my mind for no apparent reason for now.
Another thing that I want to ask you and hope you can relay to your national syphilis contact is whether or not outpatient is an option to treat Neurosyphilis.
I read the CDC guideline to treat NS is 4 x daily IV penicillin for 10-14 days OR intramuscular penicillin 2.4 (penicillin shots) AND 4x Probenecid 500mg everyday for 10-14 days. Consistently, I have found a thread of a person here undergoing the above mentioned outpatient treatment for his NS (surprisingly his titer was also 1:64 to begin with!) but that person was the only one I could find online.
Many thanks again!
Another thing that I want to ask you and hope you can relay to your national syphilis contact is whether or not outpatient is an option to treat Neurosyphilis.
I read the CDC guideline to treat NS is 4 x daily IV penicillin for 10-14 days OR intramuscular penicillin 2.4 (penicillin shots) AND 4x Probenecid 500mg everyday for 10-14 days. Consistently, I have found a thread of a person here undergoing the above mentioned outpatient treatment for his NS (surprisingly his titer was also 1:64 to begin with!) but that person was the only one I could find online.
Many thanks again!
I was able to send your question on to a national syphilis expect that I can get help with questions over my head from time to time. This is the response I got from her via email.
When the RPR fails to decline after treatment, one of two things is going on. Some people are "serofast". They are cured but the titer doesn't drop as much as expected and remains positive indefinitely. But usually there is at least a small drop in titer, then a stable but positive one.
The more serious possibility is that treatment indeed has failed. I think that's what is going on here. Treatment failure often recurs because there is asymptomatic infection of the central nervous system; benzathine penicillin, the kind used in this persons's treatment, doesn't adequately penetrate the CNS so infection persists there.
Therefore, the advice from CDC and most infectious diseases experts -- and what I always do in my practice -- is that people in your situation need a lumbar puncture (spinal tap). If the fluid shows evidence of syphilis, more intensive treatment (10 days of IV penicillin) is necessary. If the spinal fluid is normal, then it's just a serofast problem and no further treatment is needed -- i.e. his original doctor would be proved right. But he shouldn't take that chance; neurosyphilis often needs to horrible things, like stroke or blindness.
So it is a mystery to me why the questioner's public health/ID doctor has not recommended spinal tap. In my city and clinic, there would have been no hesitation about it. He should at least speak with his doctor about it. If the advice doesn't change he should seek out another ID consultation, perhaps at one of the nearby academic medical centers like UCLA, UCSF, UCSD, etc depending on where he lives.
When the RPR fails to decline after treatment, one of two things is going on. Some people are "serofast". They are cured but the titer doesn't drop as much as expected and remains positive indefinitely. But usually there is at least a small drop in titer, then a stable but positive one.
The more serious possibility is that treatment indeed has failed. I think that's what is going on here. Treatment failure often recurs because there is asymptomatic infection of the central nervous system; benzathine penicillin, the kind used in this persons's treatment, doesn't adequately penetrate the CNS so infection persists there.
Therefore, the advice from CDC and most infectious diseases experts -- and what I always do in my practice -- is that people in your situation need a lumbar puncture (spinal tap). If the fluid shows evidence of syphilis, more intensive treatment (10 days of IV penicillin) is necessary. If the spinal fluid is normal, then it's just a serofast problem and no further treatment is needed -- i.e. his original doctor would be proved right. But he shouldn't take that chance; neurosyphilis often needs to horrible things, like stroke or blindness.
So it is a mystery to me why the questioner's public health/ID doctor has not recommended spinal tap. In my city and clinic, there would have been no hesitation about it. He should at least speak with his doctor about it. If the advice doesn't change he should seek out another ID consultation, perhaps at one of the nearby academic medical centers like UCLA, UCSF, UCSD, etc depending on where he lives.
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