Management of Serofast Syphilis with Rising Titer in HIV-Infected Patients

Diagnosis and Evaluation

The Centers for Disease Control and Prevention (CDC) recommends that a fourfold increase in nontreponemal titer after initial serologic response indicates either treatment failure or reinfection, both of which require CSF examination in HIV-infected patients 1, 2, 3
A fourfold rise in titer above the established serofast baseline is considered indicative of potential reinfection, according to the CDC guidelines 1, 2
The CDC/NIH/IDSA guidelines state that when nontreponemal titers rise fourfold, a repeat CSF examination should be performed and treatment administered accordingly 1, 2

The CDC recommends treating neurosyphilis with aqueous crystalline penicillin G 18-24 million units daily for 10-14 days 1, 2
For non-neurosyphilis treatment failure, the CDC recommends benzathine penicillin G 2.4 million units IM weekly for 3 weeks 1, 2, 3

The CDC recommends monitoring clinically and serologically at 3-month intervals for HIV-infected patients 1, 6

HIV-infected patients have an increased risk for neurosyphilis, although the magnitude is likely low 1, 2
CSF abnormalities and poorer serologic responses to neurosyphilis therapy have been documented in HIV-infected individuals 1, 4