Syphilis

Stage drives the plan - Primary and secondary syphilis change almost nothing at the board. Tertiary disease is what you plan around, so ask when the infection was found, how it was staged, and whether it was actually treated. Nontreponemal titers (VDRL, RPR) are what track treatment response; treponemal tests stay positive for life and tell you nothing about whether the patient is currently controlled.

Cardiovascular syphilis - Aortitis of the proximal aorta shows up 15 to 30 years after the primary infection and gives you aortic aneurysm and aortic regurgitation. A chest X-ray is often the first clue to the aneurysm; get an echo to quantify the regurgitation and ventricular function before you commit to a plan.

Aortic regurgitation hemodynamics - If there is significant regurgitation, keep the heart rate on the fast side of normal, keep afterload low, and protect preload. Bradycardia lengthens diastole and increases the regurgitant volume, and a sudden rise in systemic vascular resistance does the same.

Document the neurologic deficit before any block - Tabes dorsalis degenerates the dorsal columns and dorsal roots: ataxia, lost vibration and proprioception, absent lower-extremity deep tendon reflexes, and brief lightning pains in the back, limbs, or face. Write the exam down before a neuraxial or peripheral block so a deficit that predates you does not get attributed to your needle.

Neuraxial in active neurosyphilis - Active neurosyphilis is a CNS infection: the CSF carries pleocytosis, elevated protein, and a reactive VDRL. Treat it first with IV aqueous crystalline penicillin G before putting a needle in that space, and use general anesthesia if the case cannot wait. A treated patient with quiet serologies and a documented baseline exam is a different conversation.

Argyll Robertson pupils - Small bilateral pupils that do not constrict to light but do constrict to near. Note them preoperatively. They are a late-syphilis sign, and you do not want to read them as a new neurologic event on emergence.

Tabetic visceral crises - About 15% of patients get episodes of severe epigastric pain with nausea and vomiting from erosive gastritis. That means a patient who may present with a full stomach and an abdomen that looks surgical but is not.

Charcot arthropathy and positioning - Loss of proprioception removes the protective reflex against mechanical trauma, so joints are already neuropathic and deformed. Pad and position deliberately, and check range of motion awake before you commit to a position the patient cannot report pain in.

Jarisch-Herxheimer reaction - Within 24 hours of the first dose of penicillin, dying spirochetes release lipoproteins that drive fever, chills, rigors, headache, nausea, tachycardia, and hypotension. Over half of primary and secondary patients get it. If a recently treated patient looks septic in the holding area, this is on the differential, and it is not a penicillin allergy.

The penicillin allergy label - Under 9% of patients reporting a penicillin allergy have it confirmed on formal testing, and roughly 80% of documented IgE-mediated allergy is lost after ten years. There is no adequate alternative to penicillin in pregnancy, so a labeled patient gets skin testing and desensitization rather than a substitute drug.

Check the HIV status - Coinfection is common, and untreated syphilis raises HIV replication rates and lowers CD4 counts. Look for the HIV status and CD4 count in the chart; it changes your read on the patient's reserve and on how aggressively the neurosyphilis was worked up.

Syphilis is a systemic infection by the spirochete Treponema pallidum, acquired sexually, vertically, or through blood. After a 20 to 90 day incubation it moves through primary, secondary, and latent stages, and in a minority of untreated patients re-emerges 2 to 50 years later as tertiary disease. Tertiary syphilis is what reaches the operating room. Cardiovascular syphilis is an aortitis of the proximal aorta appearing roughly 15 to 30 years after the primary infection, producing aortic aneurysm and aortic regurgitation. Neurosyphilis runs early as meningitis, stroke, and cranial nerve palsies, and late as tabes dorsalis and general paresis, where perivascular inflammation and gummas degenerate the dorsal columns and dorsal roots. The organism is still sensitive to penicillin, and rates are climbing, frequently alongside HIV.