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Then we have tertiary syphilis which we very rarely see these days thank goodness. It is rare. Now that does not mean we should not take syphilis seriously in its infectious stages, but this is not something that we see commonly.

Tim : Oh hang on, I just clicked on the link there. We can continue on. We are not changing slides though Lisa sorry. Just bear with us.

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Apologies everyone, we are just getting our technology sorted. Donna : Okay so now we are moving onto congenital syphilis and for me as a public health physician, this is really the pointy end of syphilis, because infectious syphilis is a curable condition. It usually does not make people terribly sick. But congenital syphilis, the way I see it is probably a failure of our health care system.

This is totally preventable. Unfortunately, we are not there at the moment and when we get to the part about the epidemiology of it I will talk more about that.

But this is what we need to be preventing, and not to be seeing. But unfortunately, we are seeing more and more of it, in not just Australia, but other parts of the Western world as well. Tim : So you know we are seeing this resurgence of syphilis and you know, just thinking through the clinical presentation, a lot of the reasons for that is that we do not see the classical presentation a lot of the time.

So it sort of, it hides and it is missed quite easily. Donna : Yes, and it you know, it is a great mimicker, so it often can be missed. And the other thing about syphilis is that it has this up to two year infectious period, where patients can be merrily spreading it without knowing.

And so that makes our life a bit difficult. So testing for syphilis. If you see a syphilitic skin lesion like a chancre or those moist, warty condylomata lata, take a dry PCR swab and that will you know, tell you the answer.

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But at the same time, it is also a good idea to take venous blood, because with venous blood, we test for the treponemal specific antigens. They stay positive for life once someone has had syphilis.

The non-treponemal part of the blood test indicates disease activity and is used to monitor response to treatment. So that is really important, because after you treat your patient you always want to know, well are they getting better and if we do not have the venous blood test to measure their RPR, we do not know if they are getting better, we do not know if they have been reinfected.

The other test, and I have noticed just from looking at some of the names of people who I recognise, I think you are working in some of the Aboriginal community controlled health services that have a point of care test, and this is something that is being subsidised by the Commonwealth Government as part of their national response to the outbreak in Aboriginal communities.

Some places will have access to a point of care testing. This is like a little test strip. You can use finger prick blood or venous blood on it and it takes 15 minutes, you know, and then you read it. A bit like a pregnancy test.

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There is no MBS rebate for this at the moment, so it is only health services that are getting it subsidised through the outbreak response. Very important to take venous blood at the same time for lab testing because otherwise we cannot monitor the response to treatment. And if you know someone has already had syphilis, do not do the point of care test because it will inevitably be positive. It will not tell you very much about what to do now. And before we move onto the next topic, is there anything that Ben or Tim you want to raise with testing? Because I actually have a question that I would like to ask our audience.



Ben : I do not know if it will ruin your question, but I was going to say sometimes I get questions from GPs when they have a query syphilis case, about exactly what they should request. I think some practice software might provide people with it, but I suppose there are a lot of different tests there and a lot of our labs if you write just syphilis serology of whatever, we will do all that automatically based on their own algorithm. And so people when they are ordering the test do not need to know what to ask. Donna : That is right.

Yes, they just need to ask for syphilis serology and all our labs in Australia will do initially the treponemal specific test, and then if it is positive, they will move on to do an RPR but if that is negative, they will just report that as negative and that is really all you need. Ben : The other thing I was going to say is, some people do not know about the PCR test for syphilis.

So it is great that it is there and a really useful part about that is that when we are getting to treatment and the length of treatment, if you can swab something and find that that ulcer is positive for syphilis, you have got a really good argument that you have got infectious syphilis and the person only therefore needs one dose of treatment which is much easier than three weekly doses. So it is really good to pounce when you see an ulcer and swab it. It is not just for academic purposes.

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Donna : Definitely. And also, if you see an ulcer you know, like it could be herpes so our labs in WA will routinely test for all of those, you know if you ask and so that is also good because it gives you a definite diagnosis and it also helps from a public health point of view, because if you know it is a chancre, you only need to contact trace back you know, three months and however long they have had the ulcer, which is much more manageable than if you are trying to contact trace back up to two years, and that is just really hard for most people.

Donna : Yes, so my question is, we are going to move to treatment next, and I would really like to find out from people, what sort of penicillin is the right treatment for syphilis? Tim : So we are putting that out there for you to answer in the question box.

We will give it a moment or two. Not many answers so far.

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So the question is what sort of, oh there it goes. Yes, here we go it is all coming in. Yes, so we are seeing mostly the correct answer. A few slightly incorrect or confusing answers. And this is a trick question in lots of ways, because people sort of get themselves caught up in the name of the penicillin and it can result in the wrong treatment.

So Ben, do you want to talk about the right treatment? Ben : Yes, so look I have seen lots of different things used for treatments. One mistake I have seen a few times is benzyl rather than bezathine penicillin. Benzathine penicillin is a long acting form. Benzyl is a short acting form, and benzylpenicillin you need to give it four hourly so not really the ideal thing. So it is benzathine. The other one is procaine penicillin which we have seen a few times.

Really, benzathine or what is sometimes just called Bicillin as well, is the correct treatment. Donna : Well it is long acting Bicillin. Because there used to be a short acting Bicillin. You cannot get that anymore, thank goodness. So you can treat syphilis with procaine penicillin injections but you need to give it daily for ten days and I would challenge any patient to present every day for ten days for a painful injection, so I would not recommend it.

Tim : And there was one answer there that I absolutely loved. It was John, no it was not John, it was someone who said, as per the guidelines. Which is the same answer I use. Donna : I must say, looking at those answers I feel quite heartened, because there is a lot of benzothine penicillin or LA, you know long acting penicillin so that is really great. And we have even got a few people giving us the correct dose which is lovely to see. Tim : Okay, well let us move onto the next slide. So this is the treatment information.

So it is a bit of you know, you can see there that is a, well it is a very viscous, thick injection. They are reasonably sizable. They need to go into the buttock and they are not particularly comfortable to give, Donna are they? Donna : No, they are not that nice to give. It is like giving toothpaste injections, you know. Two mils in each buttock. And people are quite sore afterwards.