181.3 🩺 內科專科考前版

181.3.0.1 1⃣ Neurosyphilis in HIV

  • Faster progression to neuro forms
  • LP threshold lower
  • 2024 IDSA: LP if neurologic / ocular / otic sx, or RPR ≥ 1:32 + CD4 < 350 (controversial)
  • Treatment same (aqueous PCN G × 10-14d)
  • Monitor CSF more frequently

181.3.0.2 2⃣ Congenital Syphilis 2024 Surge

  • USA: 3700+ cases 2022, projected higher 2024
  • Texas, Florida, Mississippi, California epicenters
  • Drivers: prenatal care gaps, untreated maternal, missed RPR rescreening
  • CDC 2024: RPR at first prenatal visit + 28 wk + delivery (3 timepoints) in high-prevalence areas
  • All exposed neonates: full workup (RPR, LP, long bone X-ray, CBC, LFT, eye exam, hearing) + treat if any +

181.3.0.3 3⃣ Doxy-PEP for STI Prophylaxis

  • CDC 2024 guidance
  • MSM + transgender women + > 1 STI past year
  • Doxycycline 200 mg PO within 72 hr of unprotected sex
  • Reduces syphilis ~ 80%, chlamydia 70%, gonorrhea 50%
  • Not for cisgender women (failed dPEP trial 2022)
  • AMR surveillance ongoing

181.3.0.4 4⃣ Ocular Syphilis Emergency

  • Uveitis (most common), optic neuritis, chorioretinitis
  • Sx: blurred vision, photophobia, pain
  • 急 ophthalmology consult
  • Treat as neurosyphilis (aqueous PCN G IV × 14d)
  • Steroid adjunct for inflammation
  • 2014-2024 ocular syphilis cases increased (CDC alert)

181.3.0.5 5⃣ 健保 / Taiwan

  • 通報 mandatory
  • 健保 PCN G + benzathine — covered
  • 公費 mass screening (HIV + syphilis) high-risk groups
  • å­•å©Š routine syphilis screening 1st prenatal + 32 wk (Taiwan CDC)
  • 急 治療 < 24 hr 確蚺

181.3.0.6 6⃣ PCN Allergy Desensitization (Pregnancy)

  • 圚 controlled setting (allergy / ID)
  • Incremental oral PCN doses every 15-30 min
  • Once desensitized → IV / IM PCN
  • Permanent for that drug course only (re-sensitize after)
  • Critical for syphilis in pregnancy + neurosyphilis + severe forms

181.3.0.7 7⃣ Serology Pitfalls

  • Prozone phenomenon: very high RPR titer → false neg (dilute serum first)
  • HIV + advanced: variable serology, may need PCR / LP
  • Serofast: persistent low titer post-treatment in 15-20%
  • Past treated with prior PCN-allergic: re-evaluation challenging

181.3.0.8 8⃣ Treatment Failure vs Re-infection

  • 4-fold rise titer = failure or new infection
  • LP if neurologic concern
  • Re-treat: same regimen IDSA (same stage)
  • Some advocate IV aqueous if late-stage / failure
  • Re-test for HIV