Monday, June 30, 2014
Return of the spirochete
“Example is the school of mankind, and they will learn at no other.”
Syphilis has been around at least since Europeans arrived in the Western Hemisphere. It’s a sexually transmitted disease caused by Treponema pallidum, a member of a group of corkscrew-shaped bacteria called spirochetes. Sometimes it causes no symptoms at all, but typically it initially causes a painless sore on the mouth or genitals. Later it can cause a rash. Untreated it may lead to blindness, spinal cord and brain damage, and death.
After the discovery of penicillin in the 1940s syphilis was for the first time easily curable and the prevalence of syphilis in the U.S. dropped precipitously.
I trained in the bad-old-days of the mid-90s when HIV was killing tens of thousands of people in the U.S. every year. On every inpatient ward rotation I met patients hospitalized with an opportunistic AIDS-related infection. On every ICU rotation I met patients dying of AIDS. Back then medications to treat HIV were few, new, and only modestly effective. HIV was usually a rapidly fatal disease. It was scary. Counseling patients about condom use and monogamy was not moralistic or theoretical. It had all the practical urgency of yelling at someone to get off the train tracks.
I have no evidence that HIV and the response to it was responsible for the subsequent fall in syphilis infections, but in fact syphilis did decline during the 90s and in 2000 reached its lowest rate ever in the US and was on the verge of being eliminated. You would think that a disease that can be easily diagnosed with blood tests, can be cured with antibiotics, and can be prevented with condoms would be on its way to the dustbin of history. You would be wrong.
The Centers of Disease Control and Prevention (CDC) published a review of syphilis trends in the US from 2005 to 2013. The statistics are dismaying. The number of syphilis cases almost doubled during that interval, from 8,724 cases in 2005 to 16,663 in 2013. 91% of the 2013 cases occurred in men. The number of cases in women was about the same in 2013 as in 2005. Of the male cases in 2013, 84% occurred in men who reported having sex with men.
The report breaks down the trends geographically and by ethnicity but it’s the age breakdown that I found fascinating. From 2005 to 2009 men aged 20 to 24 had the greatest percentage increase in syphilis rates, and from 2009 to 2013 men aged 25 to 29 had the greatest increase. But of course those 2 age categories are actually the same group, men born in the 1980s. I couldn’t help notice that these are the men who grew up after the bad-old-days, the men who think of HIV as the treatable chronic illness it has become, not the death sentence it was 20 years ago.
The CDC report offers wise advice to physicians. We should be testing gay and bisexual men for syphilis at least annually. Men who have multiple partners should be tested more frequently. We should be counseling consistent condom use except in prolonged monogamous relationships in which both partners have been tested.
But perhaps that won’t be enough. I have zero evidence that the attitudes about HIV contributed to the decline of syphilis in 2000 or its resurgence now, but the time course certainly seems to fit. It’s a testament to scientific research and drug development that in such a short time a disease that had the mortality of stage 4 lung cancer is now more like diabetes. But to young men this progress must make our advice about avoiding sexually transmitted diseases sound a lot less urgent, less like getting off the train tracks and more like putting on their seat belt. That complacency is a terrific opportunity for a patient and ambitious spirochete.
US Syphilis Rate Up; Mostly Gay And Bisexual Men (NPR)
Syphilis Made A Big Comeback In 2013, CDC Warns (Forbes)
CDC Reports Syphilis is Increasing in Homosexual and Bisexual Men(Science World Report)
Syphilis (CDC fact sheet)
Primary and Secondary Syphilis — United States, 2005–2013 (CDC Morbidity and Mortality Weekly Report)
Syphilis—Reported Cases by Stage of Infection, United States, 1941 – 2012 (CDC)
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
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Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.