FRI0448 FOUR CASES OF SYPHILIS MIMICKING RHEUMATOLOGICAL CONDITIONS PRESENTING TO THE GENERAL RHEUMATOLOGY SERVICE AT ST GEORGES HOSPITAL, LONDON, UK IN 2018-2019
Authors: S. Qureshi, K. Moss, A. Ezeonyeji, V. Sandhu
Journal: Annals of the Rheumatic Diseases (2020)

Background: Sir William Osler once wrote: “He, who knows syphilis, knows medicine”. Whilst the Tuskegee Syphilis trials live in infamy, the advent of succesful penicillin treatment and sexual health education resulted in the lowest recorded incidence ever in 2001 1 . Unfortunately, cases of syphilis have nearly tripled in the past decade (from 2,847 in 2009 to 7,541 in 2018 in the UK) 1 . WHO now estimates the global median prevalence of Syphilis, among men who have sex with men, is 6% 2 The current cohort of clinicians will therefore have limited clinical experience of Syphilis, which can often mimic rheumatic conditions. We present the clinical experience of a tertiary teaching centre hospital. Objectives: To identify the scope of clinical cases, with a diagnosis of Syphilis, during 2018-2019 at St Georges University Hospital, London, UK. Methods: Clinical cases were identified by health professionals and a retrospective review of medical records was undertaken. Results: There were 4 cases identified during 2018-19. Patient Age Sex Past Medical History Symptomatology Risk Factors Presumed Diagnosis Serology 1 69 Male Hypertension GCA Bilateral visual loss, rash MSM Prednisolone Tocilizumab GCA-related visual loss RPR 1:64 TPPA 1: 10248 2 46 Female Nil Joint pain and swelling, rash Hepatitis B Core Antibody positive Undifferentiated Inflammatory Arthritis RPR 1: 16 3 40 Male Nil Joint pain, alopecia, uveitis and rash, weight loss MSM Primary Syphilis RPR 1: 16 TPPA 1: 10248 4 86 Female Pulmonary Sarcoidosis, Squamous cell carcinoma of left maxillary sinus Lower motor neuron facial nerve palsy Prednisolone Sarcoidosis RPR 1:4 TPPA 1:80 GCA: Giant cell arteritis, MSM: Men who have sex with men, RPR: rapid plasma regain, TPPA: Treponema pallidum particle agglutination assay Case 1: The patient was diagnosed with bilateral uveitis secondary to primary syphilis, and immunosuppression may have contributed to this. Case 2: The rash developed after the initial presentation and an extended infection screen was performed. Case 3: The patient had a 6 month duration of symptoms and had had a negative sexual health screen 1 year prior to presentation. Case 4: The patient had no features of extra pulmonary sarcoidosis and an infectious screen was undertaken. All 4 cases were referred to the Infectious Disease Unit for treatment. 3 patients received standard treatment with Penicillin, and 1 patient received an oral course of Doxycycline, due to a penicillin allergy. 2 of the 4 cases had complete resolution of symptoms, and 2 of the cases had only partial resolution of symptoms at the time of publication. Conclusion: Syphilis can present with an inflammatory arthritis, PMR and GCA –type symptoms, ocular inflammation, neurological disturbance and rashes that can mimic autoimmune conditions. Our cases highlight the increasing incidence, as well as the risk of reactivation following immunosuppression. Current practice does not advise routine testing for syphilis prior to initiation of immunosuppressive therapy. However the rising incidence should prompt careful evaluation, and detailed sexual history, particularly in high risk groups. The diagnostic test interpretation and treatment requires close collaboration with Infectious Diseases Specialists. References: [1]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/805903/2018_Table_1_STI_diagnoses_and_rates_in_England_by_gender.ods [2]Report on global sexually transmitted infection surveillance 2018, WHO, ISBN: 978-92-4-156569-1 Disclosure of Interests: None declared