Neurosyphilis during secondary concern

[EGSA]

39 WM. Single encounter with stranger (male). Unprotected rimming (he licked me) and unprotected oral both ways.  Approximately March 15th.  (I don't have actual confirmation that he had syphilis, but it's been years since my last strange encounter... never unprotected anal).  

Never saw a chancre.  Got a rash (torso only, no hands/feet), fatigue, fever, a painless sore deep in my mouth, and a bit of a swollen lymph node behind my left ear.  So I had tests last week... HIV, chlamydia, gonorrhea, HSV all negative.  Both syphilis tests reactive, though (the one was at 1:32 titer).  

So I went to the clinic on Friday.  She gave me a shot of penicillin (2.4M units, if that sounds right).  Says that because it's high, she wants 2 more treatments.  So I'll end up getting 3 total treatments.  

This weekend, the rash has really cleared up, and I feel reasonably better (after a rough first evening).  The sore is still present in my mouth, but it seems to have changed, so I assume that it's clearing up, too.  My urethra is a bit itchy, which is strange (again, chlamydia and gonorrhea tests came back negative).

Here are my problems: (1) I'm anxious that I'll never get rid of this stinking disease (or else have to spend 10 days in the hospital, stewing over my shame).  (2) I have what I'll call a slight tinnitus (ringing in my left ear if it's quiet).  That same ear has a bit of a full-ish feeling.  I also have a bit of dizziness when walking.  I think that the lump behind my ear (same ear) may be going down, but I cant be sure.

Questions:

1.  Are my symptoms typical or common with penicillin treatment?
2.  What's the risk that secondary syphilis 13 weeks ago could have turned into neurosyphilis?
3.  Are you reasonably confident that this course of treatment will completely cure me of syphilis?  Not asking for absolutes, of course, for obvious reasons... just your thoughts.
4.  What should I look for?  Is an LP urgent? When can I relax?  
Thx.

[Edward W Hook, MD]

Welcome to the Forum.  I will be glad to comment.  From what you say, it seems clear that you have syphilis, probably in the secondary stage.  Secondary syphilis is readily treated with penicillin shot (2.4 million units of Bicillin, just what you received) and many providers treat cases they are worried about with up to three weekly shots although whether or not a single shot is sufficient is debated.  Other than a sore rear end, the additional shots will not harm you and may do some good.  The additional shots are most often given for persons who have HIV- do you?  If not your doctor may be taking the safest course of therapy.  

It also sounds as though you may already be responding to the therapy you have received.  Typically it can take a week or sore for the sore to go away (i.e. the sore you have in your mouth) although the rash may resolve more quickly.  On occasion following therapy patients may have what is called a Jarisch-Herxheimer reaction in which they have some dizziness, a fever or increased aches.  These reactions are actually a sign that the therapy is working and not something to be alarmed about.  If your tinnitus and earing problems get worse you should let your doctor know but I would give it a few days before worrying about it.

I suspect you do not need a LP at this time and can wait but if your hearing loss, tinnitus get worse  or if there are visual problems an LP may be appropriate to guide therapy.  It would not be unusual for an LP to show abnormalities but there is debate as to their clinical interpretation.  As i said, I think you can wait for an LP and if all else goes well, it may not be needed.

Response to syphilis therapy is measured best with repeat blood tests. Typically the blood tests may not respond until about three months after beginning treatment and there is clearly no reason for additional blood tests until at least a week after a month after starting therapy.  

1.  Are my symptoms typical or common with penicillin treatment?
They are certainly typical for syphilis.  

2.  What's the risk that secondary syphilis 13 weeks ago could have turned into neurosyphilis?
Clinical neurosyphilis does occur in a small fraction of secondary syphilis patients.  it is most often manifest by visual problems although ear problems can be part of the illness as well.

3.  Are you reasonably confident that this course of treatment will completely cure me of syphilis?  Not asking for absolutes, of course, for obvious reasons... just your thoughts.
Yes,, the therapy you are receiving is over and above that recommended for secondary syphilis.  It is the therapy you would receive if I was taking care of you.

4.  What should I look for?  Is an LP urgent? When can I relax?
See above.  The most important thing you can do is have a doctor who you see over time, not go from doctor to doctor. if your doctor has trouble they can call a specialist for help.  

I hope these comments are helpful.  Please let us know how things proceed.  EWH

[EGSA]

I'll try not to worry... doubt I'll be too successful with that, though.  

You've helped a ton.  Thanks so much.  

[Edward W Hook, MD]

1.  Research shows that about half of persons with secondary syphilis have abnormal LP results and in virtually all persons with secondary syphilis who do not have HIV, these abnormalities ressolve with a single injection of benzathine penicillin.  As I said above, the three inhjections your doctor plans is added value.

2.  The visual changes which occur in persons with secondary syphilis are typically decreased visual acuity and blurred vision.

Try not to worry. there is vast experience with syphilis and syphilis treatment.  You should do well.  EWH

[EGSA]

I'm sorry, can I just ask one or two follow ups?  

First of all, I am HIV negative.

1.  Would the 3 x 2.4M penicillin touch neurosyphilis?  Or would ns require a hospital stay eventually?  Again, I will find a doctor that I'm comfortable speaking with and stick with him/her, but my anxiety level is through the roof at this point.

2.  What sort of visual symptoms might manifest?  I can't seem to find that on-line.  

Thank you.

[Edward W Hook, MD]

Glad to help.  EWH

[EGSA]

Thank you, doctor.  Your suggestion to stick with a doctor is a great one, and I'll do that.