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Tuesday, January 06, 2009

Drug of choice for Tertiary Syphilis Procain Penicillin

Question 63
Drug of choice for Tertiary Syphilis
a.       Procaine penicillin
b.      Penicillin G
c.       Benzathine Penicillin
d.      Oral Penicillin
Answer
a.       Procain Penicillin
Reference;
Harrison 16th Edition Table 153-3, Page 983
QTDF
Harrison
Quality
Reader
Status
Repeat
Discussion
Treatment of Syphilis
Stage of Syphilis
Patients without
Penicillin Allergy
Patients with Confirmed
Penicillin Allergy
Primary, secondary, or early latent
Penicillin G benzathine (single dose of 2.4 million units IM, 1.2  million units in each buttock)
Tetracycline hydrochloride (500 mg PO qid) or doxycycline (100 mg PO bid) for 2 weeks
Late latent (or latent of uncertain duration), cardiovascular, or benign tertiary
Lumbar puncture
CSF normal: Penicillin G benzathine (2.4 million units IM  weekly for 3 weeks)
CSF abnormal: Treat as neurosyphilis
Lumbar puncture
CSF normal: Tetracycline hydrochloride (500 mg PO qid) or doxycycline (100 mg PO bid) for 4 weeks
CSF abnormal: Treat as neurosyphilis
Neurosyphilis (asymptomatic or symptomatic)
Aqueous penicillin G (18-24 million units/d IV, given in divided doses every 4 h) for 10-14 days
or
Aqueous penicillin G procaine (2.4 million units/d IM) plus oral probenecid (500 mg qid), both for 10-14 days
Desensitization and treatment with penicillin if allergy is confirmed by skin testing
Syphilis in pregnancy
According to stage
Desensitization and treatment with penicillin if allergy is confirmed by skin testing
Explanation
Self Explanatory
Comments
Ä     Penicillin is the DOC for Fetal Theraphy of syphilis (Nelson Table 81-5)
Ä     The signs and symptoms of syphilis are numerous; before the advent of serological testing, precise diagnosis was very difficult. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage.
Ä     The name "syphilis" was coined by the Italian physician and poet Girolamo Fracastoro in his epic noted poem, written in Latin, entitled Syphilis sive morbus gallicus (Latin for "Syphilis or The French Disease") in 1530. The protagonist of the poem is a shepherd named Syphilus (perhaps a variant spelling of Sipylus, a character in Ovid's Metamorphoses). Syphilus is presented as the first man to contract the disease, sent by the god Apollo as punishment for the defiance that Syphilus and his followers had shown him. From this character Fracastoro derived a new name for the disease, which he also used in his medical text De Contagionibus ("On Contagious Diseases").
Tips
Ä     Until that time, as Fracastoro notes, syphilis had been called the
o       “French disease” in Italy
o       “French disease” in Germany, and
o       “Italian disease” in France.
o       “Spanish disease” in Dutch 
o       “Polish disease” in the Russia
o       “Christian disease” or "Frank disease" (frengi) in Turkey
o        "British disease" by the Tahitians
Ä     These 'national' names are due to the disease often being present among invading armies or sea crews, due to their high amount of unprotected sexual contacts with prostitutes. It's interesting to notice how the invaders named it after the invaded country and vice versa.
Ä     It was also called "Great pox" in the 16th century to distinguish it from smallpox. In its early stages, the Great pox produced a rash similar to smallpox (also known as variola). However, the name is misleading, as smallpox was a far more deadly disease. The terms "Lues" (or Lues venerea, Latin for "venereal plague") and "Cupid's disease" have also been used to refer to syphilis. In Scotland, Syphilis was referred to as the Grandgore. It was also called The Black Lion.

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