Post-treatment Question

[spence300]

Dear Dr.
I contracted syphilis on November 11, 2011 in Tokyo from heterosexual oral sex. I had no primary signs but developed a rash on my trunk and inner arms in late January. In early February I was tested in London and had a positive RPR reaction with a titer of 1:16. I received an injection of 2.4 million units of Benzathine Penicillin. That night I experienced typical Jarisch-Herxheimer reaction: my rash got much worse, fever, etc. but that passed in about 18 hours.

When I got back to the states I had a second blood test to confirm the test in London (two weeks after receiving the penicillin injections) and that came back with a RPR titer of 1:32. The clinician said it was too early to retest (only two weeks) and titers can go up immediately after treatment. Is this consistent with your experience?

My question is that in the week or so before being treated the back of my head around the occipital area was very strong and I had a loud ringing in my ears. I have always had tinnitus but this was quite exaggerated. Since getting treated the pain around the back of my head has subsided but my ears are still ringing. Should I be concerned about neurosyphilis or otosyphalis and have a CSF test or am I just completely paranoid at this point (and the stress exacerbating my tinnitus)?

Thanks in advance for any insight.

[Dr. Jose Gonzalez-Garcia, MD, MRCGP, PhD]

Hello Hunter,
Thank you for pointing this out to me.  Very interesting!
I am glad that I recommended testing.
I will be very happy to help with further advice and treatment.
Kind regards,
Dr José

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Had you not already posted a question here, I would have advised you to ask this as a follow-up on your discussion with Dr. Gonzalez-Garcia on the international forum.  He would have been interested to know that you indeed had secondary syphilis (and you would have avoided the new posting fee).  I would have agreed with his advice at that time:  based on your symptoms, syphilis seemed unlikely, but testing made sense to be sure.  I'm glad you did it!

Question 1:  Your test at 2 weeks was too soon to check whether treatment was working, but it's not wasted by any means.  The effectiveness of treatment should be judged against the highest RPR or VDRL titer, which, as your own clinician said, may continue to rise for 1-2 weeks after treatment.  (Dr. Hook is the senior researcher on a new study about rising titer in the first 1-2 weeks after treatment.  It turned out to be more common than previously believed.)

Question 2:  With regard to your tinnitus, I don't think you're being "paranoid" at all; any neurological or related (e.g. ocular, otic) symptom in the context of recent syphilis should be taken seriously.  Since you have had tinnintus in the past, most likely the recently more prominent tinnitus isn't related to your syphilis.  But it would be safest to get it checked out.  I would not presume to advise a spinal fluid examination; that's a decision for a knowledgeable, in-person provider, not a distant forum moderator.

I would recommend you contact your doctor for his advice, rather than going directly to a neurologist.  Or consider an STD or infectious diseases specialist.  If you're getting care in the private sector and are in London, Freedom Health would be a good choice (you might even end up seeing Dr. G-G in person); or your local NHS GUM clinic.

Please return with a follow-up comment and let me know how this turns out.

Regards--  HHH, MD