Treatment of Nodular Syphilis in HIV-Positive Patients

Clinical Recognition

The Centers for Disease Control and Prevention recommends treating HIV-positive patients with nodular syphilis as secondary syphilis using benzathine penicillin G 2.4 million units IM as a single dose, which is the standard regimen for early syphilis regardless of HIV status 1, 2
HIV coinfection increases the likelihood of atypical syphilitic presentations, including more apparent clinical lesions and potentially accelerated disease progression, according to the MMWR Recommendations and Reports 3, 4

The CDC recommends serologic testing, including both nontreponemal and treponemal tests, for diagnostic confirmation of syphilis 1
HIV testing confirmation is also recommended, as all syphilis patients should be tested for HIV, according to the CDC guidelines 1

The CDC recommends benzathine penicillin G 2.4 million units IM in a single dose as the first-line treatment for secondary syphilis, including nodular presentations, regardless of HIV status 1, 2
For penicillin-allergic patients, the CDC recommends doxycycline 100 mg orally twice daily for 14 days 1, 2

HIV-positive patients may experience more rapid progression and more florid cutaneous manifestations of syphilis, according to the MMWR Recommendations and Reports 3, 4
Early syphilis treatment can cause transient decreases in CD4+ count and increases in HIV viral load, which typically improve after treatment, as reported by the MMWR Recommendations and Reports 3

The CDC recommends considering CSF examination in HIV-positive patients with neurological signs or symptoms, ocular or auditory symptoms, treatment failure, or very high RPR titers 1, 2
If neurosyphilis is confirmed, the CDC recommends treatment with aqueous crystalline penicillin G 18-24 million units IV daily for 10-14 days 1, 2

The CDC recommends repeat quantitative nontreponemal tests at 3, 6, 12, and 24 months to monitor treatment response 1, 2
Treatment failure is defined as failure of nontreponemal titers to decline fourfold within 6 months, according to the CDC guidelines 1, 2

The CDC recommends treating all sexual partners exposed within 90 days before diagnosis presumptively, even if seronegative, to prevent further transmission of syphilis 2