Mascolini: What are the most common mistakes HIV clinicians make in managing HIV-positive people with syphilis?
Ghanem: There are several things I would focus on. The first, and I think the most important, is not screening for syphilis nearly enough. Clinicians need to screen high-risk patients more frequently.
The second problem is not being aggressive in following up HIV-infected patients after they get treated for syphilis. You really want to bring them back in after treatment to make sure they're responding appropriately serologically.
Another thing clinicians tend to forget can be illustrated by this scenario: An HIV-infected patient comes in with early syphilis. They get the appropriate treatment. A week or 2 weeks later they call and say they're having headaches. Some clinicians don't think about the possibility of neurosyphilis because they think they've treated the syphilis and neurosyphilis can't occur after treatment. Clinicians tend to forget that neurosyphilis can occur after appropriate syphilis therapy, particularly in HIV-infected patients.
That's another reason why it's important to follow up with patients and to explain to patients what to watch for after they get treated for early syphilis: "If you develop a headache, if you notice visual changes, if you develop any neurologic function abnormality, give me a call immediately." Our study of HIV-positive people with syphilis showed that neurosyphilis can develop in those patients after they are appropriately treated for early syphilis.6
A final mistake involves the issue of early neurosyphilis. Clinicians tend to forget that early neurosyphilis does occur. They assume that neurosyphilis develops many years after the initial infection. But particularly among patients who have an immune system defect, such as people with HIV, early neurosyphilis can occur literally within days of infection. In other words you can have neurosyphilis concomitantly with primary syphilis, secondary syphilis, or early latent syphilis. In fact in our study early neurosyphilis was far more common than late neurosyphilis.6
Clinicians should remember that early neurosyphilis is something they have to look for. Whenever they're evaluating an HIV-infected patient for early syphilis, clinicians have to ask about neurological symptoms including photophobia, headache, neck stiffness, visual changes, and cranial nerve abnormalities. Doing so will help ensure that they don't miss a case of early neurosyphilis.
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