Query failed syphilis treatment? Reinfection?

[welliamin]

Dear Sir,

June 4 2008 - I went to my General Practitioner with a small pimple like thing on my penis.
June 10 2008 - My GP called me with my results that I had syphilis.
                        VDRL - 1:16
June 10 2008  - I was given 2 injections of 2.4 mil (one in each hip)
Sep  10 2008 - The value was 1:4

The doctor confirmed I was fine and not infected.

Mid Oct - I got a blister (ulcer) in my mouth

Mid Nov - Lots more ulcers - a whole line of white blisters in my mouth.
  Red rashes around bisceps. Suffering from Tinnitus since Aug 2008 (After getting an ear infection and took some antibiotics against my infection)

Mid Nov - I was  tested for Syphilis
          VDRL - 1:16

End Nov -GP sent me to a specialist (Dermatologist). Specialist did his own tests and
value was reconfirmed 1:16.

Specialist suggests to go to a neurology deptt to rule our neurosyphillis.
Is this taking too long?
Am I risking not getting injections and making it difficult to cure syphilis?

Sexual behaviour - From June 2008 till date - Kissing, letting partner masturbate myself,
                   sometimes licking/biting each other around breast area.

I had understood this was fine and there was no risk.

What is your opinion -
Have i been reinfected/ Has the treatment failed?
What is the potential treatment?


My partner is also under treatment.

He was infected 4 years ago. But did not have any follow up checkups due to misunderstanding.

His VDRL values were June 2008 - VDRL 1:16; Sep 2008 1:16. So no change for him after 2 injections.
He is now on injections every month and will have a check up in mid december.

Details of thread - http://www.medhelp.org/posts/show/560039?personal_page_id=46850&post_id=post_3692690  ;

[david_2010]

A related discussion, what should i do in this case? was started.

[welliamin]

A related discussion, Reinfection - query was started.

[Edward W Hook, MD]

You and your partner are now fully treated.  I suspect neither of your VDRL tests will go to become nor-reactive but you have had definitive treatment and your partner's test results indicate that he too has responded to therapy.  As long as you are both monogomous you are not a risk to each other and there need not be any constraints on your sexual activity.  Take care.  EWH

[welliamin]

Dear Sir,

I have had the treatment for 14 days with 18 mil units. Doctors here agreed with the unfortunate , unlucky part. But suggested that they do not know of failed syphilis treatment. However, may be it was case of neuro infection while it was primary syphilis.
He was wondering if you would agree with his theory.

Anyways, either way I was infected at a neuro level- I believe that I have been treated and I am fine?

My question to you my partner was initially infected in Nov 2004 , his VDRL value back then was 1:64. Treatment with pencillin.  After that he had no follow up controles due to medicial neglect on the doctors part.

June 2008 - He was tested again because of my condition. His VDRL value was 1:16.
Treated with single dose 2.4 million units of benzathine penicillin .

Sep 2008 - VDRL remains 1:16

He then got an 2.4 mil penicillin 3 times (once every month Sep, Oct, Nov 2008).
Dec 2008 - VDRL 1:8
Jan 2009 - No Neurosyphilis.

My question to you is - What should be our sexual behaviour. We have engaged in kissing around breast/chest/neck area and handjobs. Is this fine? Can we go back to protective sex? The doctors here are not able to suggest exactly what should be fine for us. Does he require further treatment? If yes, what and when can we go back to healthy sexual life?

Thanks v much in advance for your time.

[Edward W Hook, MD]

Unfortunately, the recommendations for treatment are given as ranges and there is variation in how to approach things.  As a potential treatment failure, most experts would err on the side of being conservative, thus 14 days of treatment would be preferable.  18 million units shold be fine.

If your partner is not infected, after a day or two of treatment there is no reason for you to be concerned about re-infecting him.  He should probably receive preventative treatment at your local health department with 2.4 million units of benzathine penicillin if he has not already had it,  just to be sure.  

There is only a need for follow-up lumbar puncture if your first one is abnormal.  If not, there is really nothing to follow up with and blood tests should be sufficient.  EWH

[welliamin]

Dear Sir,

I have beeb admitted to the hospital. I shared your view with the doc here.

He agreed on IV pencillin theraphy. He wanted to knowyour view if it would be 12mil or 18 mil units per day. I couldnot confirm that as it was not part of your earlier post.

My doc is a neurologist and said that his deptt is not going  to consider pencillin G after treatment. His colleagues differed on 12   or 18 mil per day and how many days(10 to 14 days)?

I am now on 3mil x 6 (every 4 hours) infuse.

Is 10-12 day treatment ok?Or do i need to undergo 14 day treatment?

Also if my partner is not infected(his results come soon)What should be my sexual behaviour?

Shouldwe avoid all contact (including kissing, kissing on body, handjobs) and for how long?
And what if his VDRL is still 1:16. And he also has  neurosyphillis how should we go on sexually later?

Will the follow up tests require lumbar puncture every 3 months?
Or blood tests enough to find  out the treatment of pesent stage.


Look forwardto hear from you.

Many Thanks and Regards,
W

[Edward W Hook, MD]

You are one of those unfortunate persons who have the bad luck to fail syphilis treatment.  Treatment in the hospital with 10 days of IV penicillin will be curative.  Many experts would administer two doses of 2.4 million units of benzathine penicillin G (the type is penicillin is very important) as intramuscular injections at the completion of your IV therapy, the first dose on the day the IVs are finished and the second a week later just to be completely sure.  After that, even if your blood tesat values do not go down, you should consider yourself cured as long as the values do not go up 4-fold.  EWH  

[welliamin]

Dear Sir,

I have got back the results for lumbar puncture.
TPHA - positive 1:32
VDRL - Negative

Blood tests earlier were all VDRL.

So June 1:16  , Sep 1:4 and Nov 1:16 again.

The doctor suggests that I will have to get admitted in the hospital and will be treated for 10 days with penicillin via a tube in place on injections.

My question to you is - Is this the right way to proceed? Does it also cover the VDRL positive in blood?

What does this actually mean? Have I been infected for a very long time? Can this still be cured? Serious health consequences. Or anything that I should be aware of in your advice.

I look forward to hear from soon. As I will be admitted to a hospital in a couple of days.

Thanks v much.

W

[Edward W Hook, MD]

It would help to sort this out if you could find out which values were VDRLs and which were RPRs. Specifically, RPR results sometimes are a bit higher than VDRL and, as result one may think they have failed treatment when what is seen is acutally due to use of a different test.  If your 1:4 was a VDRL and subsequent 1:16s are RPRs, you may not have failed therapy at all and I would suggest a re-test with the VDRL test.

As far as what treatment, re-treatment with 2.4 million units of benzathine penicillin is recommended although some experts would give you that dose of penicillin once a week for three weeks in a row.

One both you and your partner have received penicillin within a few days of one another, there is no further risk of re-infection between the two of you.  

There are no studies to tell us how likely a second relapse is.  It is described but is rare.  EWH

[welliamin]

**Forgot to add something about relapse. So posting again. Please ignore previous post **

.1. Do you have HIV?  HIV seems to slightly increase the risk for relapse.

--No HIV or any other STD.

2.  Have you or your partner had other partners since June (exposure at any site would count)? If so, this, combined with the symptoms you describe might suggest re-infection rather than relapse.

--No other partners for either of us.

3. Are all of the results you mentioned VDRL tests or were some RPR tests? While the two tests measure the same thing, they are not interchangeable

-- I believe that it is combination of both. No chance of lab error. As it was re-checked twice.

What should be the treatment according to you for relapse in my case if I am detected for Neurosyphilis and if not?
What should be our sexual behaviour meanwhile to avoid any complex problems further?
What are the chances that syphilis replases again in the future?

p.s. -  I am not based in US.

[welliamin]

1.  Do you have HIV?  HIV seems to slightly increase the risk for relapse.
No HIV or any other STD.

2.  Have you or your partner had other partners since June (exposure at any site would count)? If so, this, combined with the symptoms you describe might suggest re-infection rather than relapse.

No other partners for either of us.

3. Are all of the results you mentioned VDRL tests or were some RPR tests? While the two tests measure the same thing, they are not interchangeable

I believe that it is combination of both. No chance of lab error. As it was re-checked twice.

What should be the treatment according to you for relapse in my case if I am detected for Neurosyphilis and if not?
What should be our sexual behaviour meanwhile to avoid any complex problems further?

p.s. -  I am not based in US.

[Edward W Hook, MD]

In managing persons with syphilis the blood test (VDRL) is used to define response to therapy.  It sounds as though your initial response to therapy was appropriate with your VDRL dropping from 1:16 to 1:4.  Then things get complex.  You blood tests again increased to 1:16 where they have been repeatedly.  This increase in your titer after an initial therapeutic response can be due to either a relapse following partially successful treatment of re-infection and trying to sort one from the other out is often quite difficult (a third, rather unlikely possibility might be that there was a lab error but this is unlikely).  Either way, you need repeat treatment and the CDC would recommend a lumbar puncture to evaluate whether or not otherwise asymptomatic neurosyphilis may have contributed to your possible relapse.  

Several questions occur which might help us to assess whether re-infection or relapse is the best explanation for what is going on:

1.  Do you have HIV?  HIV seems to slightly increase the risk for relapse.
2.  Have you or your partner had other partners since June (exposure at any site would count)? If so, this, combined with the symptoms you describe might suggest re-infection rather than relapse.
3. Are all of the results you mentioned VDRL tests or were some RPR tests? While the two tests measure the same thing, they are not interchangeable.  

Either way, you both need re-treatment at this time.  Hope this starts to address your questions and we can discuss more once you have answered the questions I just posed.  EWH