Syphilis: Screening and diagnostic testing
- Charles B Hicks, MD
Charles B Hicks, MD
- University of California, San Diego
- Meredith Clement, MD
Meredith Clement, MD
- Division of Infectious Diseases
- Duke University Medical Center
Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. The manifestations of this disease are notoriously protean, with different stages occurring over time in untreated infection [1-3]. Patients may seek evaluation for symptoms or signs of primary infection (eg, chancre), secondary infection (eg, diffuse rash), or tertiary infection (eg, symptoms of aortic insufficiency). Alternatively, patients may be completely asymptomatic and only identified on routine screening. The diagnosis of syphilis is most commonly made by serologic testing, a technique first described by Wasserman in 1906 .
The appropriate use and interpretation of diagnostic testing are important for optimal patient management. Testing for syphilis will be reviewed here. The pathophysiology, natural history, clinical manifestations, and treatment of this disorder, as well as the laboratory monitoring of patients undergoing therapy, are discussed elsewhere. (See "Syphilis: Epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients" and "Syphilis: Treatment and monitoring".)
WHOM TO TEST
Diagnostic testing for syphilis should be performed on patients with signs or symptoms of infection. In addition, asymptomatic patients should be screened for syphilis if they are at high risk for having acquired disease or for transmitting disease to others. Serologic testing is generally used to make a diagnosis of syphilis. The approach to testing is described below. (See 'Approach to testing' below.)
All persons who are diagnosed with a new syphilis infection should be treated. In addition, they should be offered HIV testing, as well as screening for other sexually transmitted infections. (See "Syphilis: Treatment and monitoring" and "Screening for sexually transmitted infections".)
Symptomatic patients — Since syphilis can present with a wide range of signs and symptoms, the threshold for serologic testing should be low. We test the following groups of patients regardless of their apparent risk behaviors:
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- WHOM TO TEST
- Symptomatic patients
- Asymptomatic patients
- DIAGNOSTIC TESTS
- Serologic tests
- - Nontreponemal tests
- - Treponemal tests
- - Rapid serologic tests
- Direct methods for diagnosis
- APPROACH TO TESTING
- Serologic testing algorithms
- Testing for neurosyphilis
- INTERPRETATION OF SEROLOGIC TESTING
- Positive nontreponemal/positive treponemal test
- - Patients without a history of syphilis
- - Patients with a history of treated syphilis
- Positive nontreponemal/negative treponemal
- Positive treponemal/negative nontreponemal test
- Negative nontreponemal test in early syphilis
- - Testing prior to antibody formation
- - Prozone reaction
- - Early treatment
- Negative nontreponemal test in late syphilis
- LATENT SYPHILIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS