Dr. med. Dirk Manski

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Syphilis: Diagnosis and Treatment

Review-Literature: (CDC Guidelines, 2006) (Golden et al., 2003) (Parkes et al., 2004) (RKI-Ratgeber, 2010)(Schneede et al., 2003) (Zeltser and Kurban, 2004).

Diagnosis of Syphilis


Treponema pallidum can be diagnosed in fluids from skin lesions of primary and secondary syphilis with dark field microscopy or by immunohistochemistry. Corkscrew movements of spirochetes can be seen in wet mount specimens. False-positive results are possible by non-pathological spirochetes, but the sensitivity of microscopy is high.

Serologic Testing for syphilis

The specific diagnosis of syphilis is achieved with Treponema pallidum hemagglutination test (TPHA) and Fluorescent Treponemal Antibody Absorption (FTA-Abs). The disease activity syphilis (follow-up) is done with Venereal Disease Research Laboratory (VDRL) or Rapid plasma reagin (RPR) tests:


Treponema pallidum hemagglutination test, enables a specific syphilis diagnosis through specific hemagglutination of red blood cells bound with Treponema.


Fluorescent Treponemal Antibody Absorption test, enables a specific syphilis diagnosis. Treponema pallidum is fixed on slides and incubated with patient serum. Spezific syphilis antibodies of the patient are detected with fluorescent anti-human antibodies.


Rapid plasma reagin, screening test for syphilis. RPR detects reagin, an antibody present in serum or plasma from persons with syphilis or other treponemal diseases.


Venereal Disease Research Laboratory test. Non-specific test for the disease activity of syphilis, detects lipidspecific antibodies.

Further Diagnostic Studies

An HIV test is rational. An accurate history and examination of any sexual partners is necessary.

Treatment of Syphilis

Treatment regims differ between early syphilis (primary syphilis, secondary syphilis and early latent syphilis) and late syphilis (late latent syphilis and tertiary syphilis).

Treatment of Early Syphilis:

First choice to treat early syphilis is Benzathine penicillin G 2.4 million IU i.m. once.

Alternative Therapy (allergie to penicilline): Ceftriaxone 2 g i.m. or i.v. for 14 days, doxycycline 100 mg p.o. 1-0-1 for 14 days or azithromycin 2 g p.o. once.

Treatment of Late Syphilis:

First choice to treat late syphilis is Benzathine penicillin G 2.4 million IU i.m. at day 1, 8 and 15 (three doses in two weeks). Neurosyphilis should be treated with penicillin G 3–4 million IU every 4 h i.v. for 14 days.

Alternative Therapy (allergie to penicilline): Ceftriaxone 2 g i.m. or i.v. for 14 days.

Treatment of Congenital Syphilis

The vertical transmission is likely prevented, if treatment of the mother is started before the 16th week of pregnancy. The pregnant mother should be treated with Benzathine penicilline, see above mentioned recommendations. Infants or children with congenital syphilis should be treated with e.g., procaine penicilline i.m. in a single daily dose for 10 days (50 000 units/kg/dose).

Jarisch-Herxheimer reaction

Jarisch-Herxheimer reaction is a systemic reaction due to massive bacterial antigen-release after starting antibiotic therapy. Symptoms: fever, muscle pain, headache, skin rash. The Jarisch-Herxheimer reaction occurs most often in patients with early syphilis. Treatment aims to relieve the symptoms with paracetamol and, if necessary, glucocorticoids.


Sexual abstinence, use of condoms, avoidance of risky sexual behaviour, antibiotic prophylaxis with azithromycin-monthly doses in high-risk groups.



Since 2001 (Infektionsschutzgesetzes IfSG): reporting (without personal data) is mandatory.


Syphilis is a reportable disease in every state. Reporting can be provider and/or laboratory-based. Clinicians who are unsure of local reporting requirements should seek advice from local health departments or state STD programs (CDC 2002).

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


Center for Disease Control and Prevention.: Sexually transmitted diseases treatment guidelines 2006.
in: MMWR
2006; 55 (No. RR-11): 1–93.

Golden u.a. 2003 GOLDEN, M. R. ; MARRA, C. M. ; HOLMES, K. K.: Update on syphilis: resurgence of an old problem.
In: Jama
290 (2003), Nr. 11, S. 1510–4

Parkes u.a. 2004 PARKES, R. ; RENTON, A. ; MEHEUS, A. ; LAUKAMM-JOSTEN, U.: Review of current evidence and comparison of guidelines for effective syphilis treatment in Europe.
15 (2004), Nr. 2, S. 73–88

RKI-Ratgeber: Infektionskrankheiten – Merkblätter für Ärzte: Syphilis.
Downloaded from www.rki.de, 10.5.2010.

Zeltser und Kurban 2004 ZELTSER, R. ; KURBAN, A. K.: Syphilis.
In: Clin Dermatol
22 (2004), Nr. 6, S. 461–8

  Deutsche Version: Diagnose und Therapie der Syphilis (Lues)