Emergency Department Diagnosis and Management of Patients With Syphilis (Infectious Disease CME and Pharmacology CME)

Publication Date: January 2026 (Volume 28, Number 1)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 01/01/2029.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME credits and 3 Pharmacology CME credits, subject to your state and institutional approval.

Authors

Hilary H. Beason, MD, FACEP

Assistant Professor, Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; Director of Ultrasound Education, Cullman Regional Medical Center Primary Care for Emergency Medicine Fellowship Program, Cullman, AL

Chen He, MD

Residency Program Director and Assistant Professor, Department of Emergency Medicine, Mount Sinai Morningside – Mount Sinai West; Icahn School of Medicine at Mount Sinai, New York, NY

Peer Reviewers

Erik Blutinger, MD, MSc, FACEP

Assistant Clinical Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY; Attending Physician, Mount Sinai Queens, Queens, NY

Daniel J. Egan, MD, MBA

Associate Professor of Emergency Medicine, Harvard Medical School; Vice Chair of Education, Mass General Brigham Emergency Medicine, Boston, MA

Abstract

Syphilis is a sexually transmitted infection known as the “great imitator” due to its large variety of presentations, depending on the stage of the disease. Because of its prevalence and the possibility of severe outcomes, emergency clinicians must remain vigilant when evaluating patients, especially those in high-risk groups. Clinicians should be familiar with the treatment recommendations for the various stages of syphilis, including alternative regimens, when national drug shortages limit the availability of first-line treatments. This review discusses the various presentations, diagnostic options, and potential complications for syphilis, as well as current and emerging treatment recommendations.

Case Presentations

CASE 1

A 24-year-old man presents to the emergency department after he was called back for a positive screening result on rapid plasma reagin (RPR) testing…

He reports no symptoms at this time, but says he was treated for primary syphilis 2 years ago.
He is sexually active with both men and women, intermittently uses condoms, and takes pre-exposure prophylaxis (PrEP) for HIV. He presented for testing due to concerns about STI exposure from a sexual partner.
As the patient asks, “Do I have syphilis again?” you consider whether you should order additional testing or treat him for active infection…

CASE 2

A 30-year-old pregnant woman comes to the ED for rash…

She said said she just had her pregnancy confirmed at a local women’s clinic and is at 25 weeks‘ gestation with her first baby, but she has not yet had any prenatal testing.
She reports a recent upper respiratory infection, after which she developed a diffuse rash 2 days ago. The rash is on her trunk, arms, legs, and neck. The lesions are small, oval-shaped, and pink in color. There is no involvement of her palms and soles.
She is sexually active with the baby’s father and does not use condoms.
She reports a childhood allergy to penicillin but does not know what reaction she had.
You consider whether you should treat this patient empirically for syphilis, and what antibiotics you would give her…

CASE 3

A 65-year-old woman presents with family for progressively odd behaviors…

Her family reports that she has seemed moody and sometimes agitated.
She recently retired from her job, has been more irritable with friends and family, and has been complaining of memory problems and “brain fog.”
On examination, she is alert and oriented to person, place, and time, but is slow to respond to questions. Her vital signs are normal, and she does not have any focal neurological complaints.
You consider ordering an RPR test, even though she denies being sexually active…

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.