RPR Test

I am a 35 yr old male who has been experiencing rapid patchy hair-loss for the last 3 months or so.  My GP did some general tests - thyroid and CBC and iron levels which came back normal.  She referred me to a dermatologist who did a biopsy which indicated alopecia areata with a syphillistic patern.  I had a situation about 12 months ago where there was a potential std exposure which I voluntarily had myself screened for (all of which were negative).  The syphilis test was an RPR done at 19 days and again just recently at 12 months.  Is there any way that I could have syphilis with a negative RPR?  I have read that an RPR is not always accurate.  Should I take a different test..or would these tests be conclusive??

[H. Hunter Handsfield, M.D.]

Welcome to the forum.  Bottom line:  The RPR rarely lies in situations like this, and your negative RPR is strong evidence against syphilis.  However, to be certain you should also have a confirmatory syphilis blood test; more comments below.

As you probably have learned from your dermatologist, there can be overlap in the appearance of scalp hair loss of the sort called alopecia areata and the typically irregular ("moth eaten") pattern of hair loss associated with secondary syphilis.  I'm not sure how to interpret your biopsy, however.  Maybe you are confusing the biopsy result with the hair loss pattern.  Are you certain the biopsy showed a "syphilitic" pattern (?).  Or was that how the dermatologist described your hair loss?  Further, the diagnosis of syphilis by biopsy can be imprecise.  The microscopic changes of syphilis are nonspecific, and can be seen in other pathologic processes.

Another potentially reassuring factor:  if you are in the US, UK, or elsewhere in westen Europe, the risk of syphilis from a single commercial sexual exposure is very low.  There are only about 20,000 new cases of syphilis per year in the US, and two thirds of those occur in gay and bisexual men.  The disease is even more rare in western Europe.

Returning to the blood test:  It is  rare for the RPR to be negative in syphilis a year in duration -- but it can occur, sometimes due to a laboratory issue called the "prozone" effect.  You definitely should have a confirmatory blood test, either a syphilis EIA (enzyme immunoassay) or a TPPA test (Treponema pallidum particle agglutination).  Your dermatologist probably is already planning on it; you may find that testing is already underway on the original blood specimen.  If not, have it done now.  You can expect it to be negative, at which point you can put syphilis to rest.

I hope this helps.  Please return with a follow-up comment to let me know how it all turns out.

Regards--  HHH, MD

[mlg750]

Thanks for your response.  The dermatologist sent the "punch cut" biopsy out to a lab and gave me the interpreted results.  The dermatologist originally did not think that a biopsy was necessary - she said it was up to me whether I wanted an elective biopsy to give me peace of mind about the prognosis of my hair loss.  The outsourced lab results were conveyed to me as a syphilstic pattern or syphiistic indication (I can't remember the exact words).  The dermatologist said that they would like to do some further tests at which point I indicated that I already had an RPR done recently.  The dermatologist said that there was no further testing needed due to the fact that this would be the test that they would do anyway - and that there was no need for me to worry.  

For reassurance, I called my GP and told her about the dermatologist's comments and the fact that I received independent RPR tests.  Her comment was that - with two negative tests, there would be nothing to treat - even if syphilis was treated and cured, it would show up on an RPR up to a year after a possible exposure.  With no treatment, it would definitely be indicated on the test.

Also - the dermatologist biopsy was a microscopic biopsy of the skin and hair with no blood drawn. Additionally  I live in the eastern part of the United Stated and have always been a heterosexual male and am not a drug user.

Also, i have never had any other indications of STD's.  My skin has always been problematic since I was young with eczema and minor skin irritations - but no cancers on any part of my body that I can discern.  

My dermatologist said to me that syphilis was rare and that if the RPR was negative, don't worry about it.  Should I just relax, or do I really need to get these other syphilis tests that you suggest??

[H. Hunter Handsfield, M.D.]

This sounds like the dermatologist wrote "syphilitic pattern" on the biopsy requistion -- i.e. was describing your hair loss pattern.  Pathologists often repeat the reason for the biopsy in dictating the result, so the same words could show up there.  You need to concentrate on the final, bottom line result in the biopsy report; forget all that precedes the bottom line.

In general, dermatologists are highly expert in syphilis; if your was confident syphilis isn't the problem, you can rely on it.  In fact, if he thought you had syphilis, he probably would be quite exciting because of the opportunity to diagnose a rare and interesing condition.  He probably hasn't had the opportunity to see someone with syphilis for many years!

Your GP is correct about the reliability of RPR, especially done twice with negative results.  I might still be concerned about the rare possibility of false negative RPR in secondary syphilis, but not with 2 negative results.

All things considered, it seems syphilis has definitely been ruled out and you shouldn't worry about it.  On the other hand, a syphilis EIA is easy and cheap, so if one more test would reassure you even more, it shouldn't be a problem.  This is not code to mean I really think you might have it.  I do not, and if I were in your situation, I would not feel a need for additional testing.

If your GP still isn't interested in doing a syphilis EIA, you could visit your nearest Red Cross or other blood donation center and give a pint.  Syphilis EIA is automatic on all blood donors; if the blood bank doesn't contact you within a couple days about a positive result, you'll know it was negative.  And you'll feel good about doing a valuable civic duty.  (Don't acknowledge any concern about syphilis in questions or check-lists they ask donors to complete.)

Bottom line:  For sure no syphilis, but feel free to seek one more test if it will calm your nerves.

[mlg750]

Thank you very much..I really appreciate your comments and value your opinions..my worrying is probably making my hair loss worse...I should just chill out!

[mlg750]

As a follow up, I did for piece of mind get a confirmatory TPPA test.  Thankfully the result was negative.  I am assuming there is no prozone effect possibility for the TPPA??  I will say it was difficult finding someone to perform this test with a negative RPR.  

[mlg750]

Sorry to harp on this, but I have one more question.  Along with the symptoms I have already described, I have been experiencing a stiff neck and sore throat.  I have also noticed a slight rash on my back and have been lethargic in general.

Is it possible that the "Syphilitic" diagnosis of may hair and skin biopsy could be accurate?  Is there any way that the disease could be present with a negative RPR and TPPA blood test a year in duration?  I know my question my seem crazy but it just seems that my symptoms similar to those of secondary Syphilis.

Thanks in advance for addressing my concern.

[H. Hunter Handsfield, M.D.]

First, the premise is wrong.  From what you wrote, there was no "syphilitic diagnosis" according to biopsy report.  Second, there is no such thing as prozone for TPPA.  It is the ultimate definitive test and proves beyond doubt that you do not have syphilis.  Your symptoms mean nothing and neither does the pathology.

Please accept the overwhelming evidence plus the reasoned reassurance you have had, and move on with your life.  Forget syphilis forever.