Dawaa Reference

infectious

Syphilis (Primary, Secondary & Early Latent)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources4 sources

CDC STI Treatment Guidelines 2021 · WHO Guidelines for the Treatment of Treponema pallidum 2016 · BASHH UK national guidelines for the management of syphilis 2024 · Syphilis - disease-level clinical article (syphilis-full.txt)

Verified against3 documents
  • BASHH UK national guidelines for the management of syphilis 2024
  • Syphilis - disease-level clinical article (syphilis-clinical.txt)
  • Syphilis - disease-level clinical article (syphilis-full.txt)

Verified date2026-08

Presentation reference

Is it this?

Reference only, to read alongside your own examination.

Symptoms — what the patient reports (6)

  • Secondary-stage illness brings fever, muscle aches, headache, loss of appetite, sore throat, weight loss, and joint pain [fever · headache · joint pain · muscle pain · poor appetite · sore throat · weight loss]
  • Tabes dorsalis causes an unsteady walk, poor balance, stabbing leg pains, bladder problems, numbness, and vision changes [numbness · unsteadiness]
  • Early general paresis presents with mood swings, irritability, personality shift, sleep pattern changes, and forgetfulness [irritability · memory loss]
  • Advanced general paresis adds unstable mood, poor memory and judgment, confusion, depression, agitation, psychosis, delusions, and seizures [confusion · delusions · irritability · low mood · memory loss · seizures]
  • Meningeal neurosyphilis produces headache, nausea, vomiting, a stiff neck, light sensitivity, cranial nerve problems, and seizures [headache · nausea · neck stiffness · photophobia · seizures · vomiting]
  • Meningovascular neurosyphilis starts with vague headache, nausea, vomiting, and dizziness before focal deficits appear [dizziness · headache · nausea · vomiting]

Signs — what you find (12)

  • Primary syphilis: a painless, firm ulcer with a raised, thickened rim, about 1 to 2 cm across, and a clean base
  • HIV-positive patients often develop more than one chancre at once
  • Painless, rubbery groin node swelling, sometimes on both sides, is found in up to 80% of primary-stage patients [lymphadenopathy]
  • Secondary syphilis produces a widespread blotchy rash that classically reaches the palms and soles, plus mouth lesions [rash]
  • Individual secondary lesions are usually under 6 mm across but can enlarge to 2 cm
  • Secondary-stage lesions are typically symmetric, scaly, and copper- or ham-colored, without itching [scaling]
  • Condyloma lata appear as raised wart-like plaques with a flat top, pink defined edges, and a reddened center [plaques · redness]
  • Malignant syphilis shows ulcerated, oval, dying skin lesions topped by a firmly stuck thick crust on the face, limbs, and trunk [skin lesions]
  • Cardiovascular syphilis most often causes an ascending aortic aneurysm, seen in nearly half of affected patients
  • Tabes dorsalis exam shows a positive Romberg sign along with Argyll Robertson pupils, eye muscle palsies, weak reflexes, and Charcot joints
  • Newborns with congenital syphilis most often show a widespread blistering rash, anemia, jaundice, and an enlarged liver and spleen [anaemia · hepatomegaly · jaundice · rash]
  • Classic late congenital stigmata include a saddle-shaped nose, a bulging forehead, bowed shins, and notched, peg-shaped upper incisors

Tests (12)

  • Darkfield microscopy gives an instant positive diagnosis but misses as many as 20% of true cases
  • Nontreponemal VDRL and RPR screening tests do not turn positive until after the primary chancre has formed
  • Nontreponemal tests false-positive in 1-2% of cases, so a confirmatory treponemal antibody test is required
  • FTA-ABS and TPPA are the preferred confirmatory treponemal tests across all disease stages
  • Treponemal antibody tests remain positive for life, so they cannot track disease activity over time
  • A cerebrospinal fluid work-up is warranted when the serum RPR titer reaches 1:32 or higher
  • CSF VDRL testing is specific for neurosyphilis but detects only 67% to 72% of actual cases
  • Neurosyphilis is very unlikely when both the CSF VDRL and CSF treponemal test come back negative
  • Rapid point-of-care testing needs only a finger-stick blood drop and gives a result in 15 to 30 minutes
  • Chest x-ray can first suggest an aortic aneurysm, a CT scan confirms it, and echocardiography checks for aortic regurgitation
  • Fetal ultrasound from 18 weeks gestation can show liver enlargement, an oversized placenta, and hydrops fetalis
  • Over three-quarters of infants with a placenta above the 90th percentile for their birth weight turn out to have congenital syphilis

If not this — what else fits (12)

  • Behcet syndrome
  • Chancroid
  • Contact or atopic dermatitis
  • Dementia
  • Erythema multiforme
  • Genital herpes
  • Granuloma inguinale
  • Lymphogranuloma venereum
  • Mononucleosis
  • Pityriasis rosea
  • Psychiatric illness
  • Viral exanthema

SourceStatPearls "Syphilis" - disease-level clinical article

Presentation findings are traced to the source above.

Rx: Main treatment | Penicillin allergy - parenteral alternative

MAIN TREATMENT - choose one

1

BENZATHINE BENZYLPENICILLIN

1st line

Forminjection

Adult dose and duration

2.4 million units IM as a single dose (administered as two 1.2 million unit injections in separate gluteal sites) - Single dose

Paediatric dose

Children with early acquired syphilis: 50,000 units/kg IM single dose (max 2.4 million units). Congenital syphilis requires IV aqueous crystalline penicillin G in a specialist pediatric unit.

Dose source

BASHH UK national guidelines for the management of syphilis 2024

Why

Long-acting depot penicillin that maintains sustained treponemicidal blood levels after intramuscular injection, matching the slow replication cycle of Treponema pallidum; the standard treatment for early syphilis.

Cautions
  • MUST be administered INTRAMUSCULARLY ONLY; accidental IV administration can cause cardiac arrest and death.
  • Warn patient about Jarisch-Herxheimer reaction (fever, chills, headache, tachycardia) starting within 2-12 hours after injection.
  • Perform baseline quantitative non-treponemal serology (VDRL/RPR) and repeat at 6 and 12 months to confirm cure.
Egyptian brands
Egyptian brandManufacturerIndicative price
HAYA BENZ-R 1.2 M.I.U. VIAL FOR I.M INJ.SEDICO > HAYA PHARM-EGYPT5.06 EGP
PENICID LA 1 200 000 UNITS VIALCID6.50 EGP
BENZACILLIN 1.2 M.I.U.FOR I.M.INJ VIAL.EL NASR7.00 EGP
RETARPEN 1.2 M.I.U. VIALSANDOZ > OCTOBER PHARMA10.50 EGP
LASTIPEN 1 200 000 IU VIALMISR12.00 EGP
BENZABIOTIC 1.2 M.I.U. I.M. VIAL.SEDICO16.00 EGP
DEPO-PEN 1.2 MIU VIAL.MUP25.00 EGP
PENCILONG (PENCITARD) 1200000 I.U./VIALNCPC NORTH BEST CO > ACDIMA INTERNATIONAL TRADING25.00 EGP
2

REFERRAL & SAFETY-NETTING (NO DRUG THERAPY)

1st line
Dose source

Syphilis - disease-level clinical article (syphilis-clinical.txt)

Why

Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen.

Cautions
  • RED FLAG - Doxycycline (and the tetracyclines) must not be used to treat syphilis in pregnancy. There is no proven penicillin alternative in pregnancy; penicillin-allergic pregnant patients need skin testing/desensitization instead.
  • RED FLAG - The Jarisch-Herxheimer reaction (fever, headache, myalgia, rash within hours of the first antibiotic dose) can follow the first treatment dose; in pregnancy it carries a higher risk of obstetric complications.
3

DOXYCYCLINE

2nd line

Strength100 mg

Formoral.solid

Adult dose and duration

100 mg twice daily x 14 days

Paediatric dose

Contraindicated in children under 8 years. A penicillin-allergic child with syphilis needs specialist desensitisation, or a specialist opinion on the alternatives. The Egyptian National Drug Formulary - Antimicrobial 2023, doxycycline monograph, gives the reason: used while the teeth are still forming - the second half of pregnancy, infancy, and childhood up to 8 years - it can stain the teeth permanently, leave the enamel underformed, or discolour tissue, and although long courses carry more of this risk, repeated short courses have done it too.

Dose source

BASHH UK national guidelines for the management of syphilis 2024

Why

Doxycycline 100 mg BID for 14 days is the primary alternative for non-pregnant adults with penicillin allergy. Pregnant patients with penicillin allergy MUST undergo penicillin desensitization.

Cautions
  • Pregnant women with syphilis who are allergic to penicillin MUST be desensitized and treated with benzathine penicillin G; doxycycline is contraindicated.
  • Requires rigorous serological follow-up at 3, 6, 9, and 12 months.
Egyptian brands
Egyptian brandManufacturerIndicative price
FARCODOXIN 100MG 10 CAPS.PHARCO11.00 EGP (1.10/unit)
DOXY M.R.100 MG 10 CAPS.ADWIA12.00 EGP (1.20/unit)
GRANUDOXY 100MG 10 F.C. TAB.GLOBAL NAPI PHARMACEUTICALS > PIERRE FRANCE12.00 EGP (1.20/unit)
DOXYDOX 100 MG 10 CAPS.EIPICO23.00 EGP (2.30/unit)
DOXYMYCIN 100 MG 10 CAPS.EL NILE.30.00 EGP (3.00/unit)
TABOCINE 100MG 10 CAPS.TABUK PHARMACEUTICAL MANUFACTURING COMPANY > TABUK PHARMA46.00 EGP (4.60/unit)
VIBRAMYCIN 100MG 10 CAPS.PFIZER65.00 EGP (6.50/unit)

PENICILLIN ALLERGY - PARENTERAL ALTERNATIVE

4

CEFTRIAXONE

Penicillin allergy - parenteral alternative

2nd line

Strength1000 mg

Forminjection

Adult dose and duration

1 to 2 g IM or IV once daily x 10 to 14 days

Paediatric dose

No paediatric syphilis regimen is stated in the documents held here. MSF gives ceftriaxone 50 to 100 mg/kg once daily for severe bacterial infection generally, which is not a syphilis regimen.

AWaRe

WATCH group - carries resistance cost. Egyptian EML 2025.

Dose source

Syphilis - disease-level clinical article (syphilis-full.txt)

Why

An earlier review refused this because MSF's ceftriaxone monograph names neurosyphilis and no course length. Re-opened under the two-claims rule: the condition's own article carries both claims. Indication - the article reports that the CDC, the European guidelines and the WHO all accept ceftriaxone as a reasonable alternative to penicillin in syphilis, where a shortage, a severe allergic reaction, a refusal or some comparable reason rules penicillin out. Dose - the alternatives it lists are doxycycline at 100 mg orally, twice a day for 14 days; ceftriaxone given intramuscularly or intravenously at 1 to 2 g daily, for 10 to 14 days; and tetracycline, 100 mg orally, 4 times a day across 14 days. Benzathine penicillin remains first line and doxycycline remains the oral penicillin-allergy option.

Cautions
  • MSF's ceftriaxone monograph names only the late form of the disease in its indications - its list is of severe bacterial infection: septicaemia and meningitis, pneumonia, typhoid, shigellosis, leptospirosis, pyelonephritis, the tick-borne relapsing fevers and neurosyphilis among them. The early-syphilis indication and the 10-to-14-day course both come from the disease article.
  • PREGNANCY - the article is explicit that this is not a substitute. Nothing else has been shown to be an acceptable alternative to penicillin for syphilis in pregnancy. The pregnant woman who reports penicillin allergy is therefore skin tested to establish what her real risk is, and desensitised so that penicillin can be given.
  • The same article states both sides of the pregnancy question and both are printed here: doxycycline and the tetracyclines in particular are to be avoided in the later stages of pregnancy, and there is too little data on ceftriaxone and the cephalosporins for them to be used - yet where an alternative drug is genuinely unavoidable, ceftriaxone is the one it suggests (Syphilis - StatPearls - NCBI Bookshelf, NBK534780).
  • Most reported penicillin allergy is not allergy. Confirm it before abandoning benzathine penicillin, which is the proven treatment.
  • A Jarisch-Herxheimer reaction may follow the first dose of any effective treponemal treatment - warn the patient.
Egyptian brands
Egyptian brandManufacturerIndicative price
ZOXIDEL 1 GM PD. FOR I.M. INJ.RAMEDA > DELTA PHARMA22.00 EGP
CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA)KAHIRA29.00 EGP
ZOXIDEL 1 GM PD. FOR I.V. INJ.RAMEDA > DELTA PHARMA29.00 EGP
WINTRIAXONE 1 GM PD. FOR I.V INJ.SANOFI48.00 EGP
VOTRIAXONE 1 GM I.M VIALCHEMIPHARM56.00 EGP
OFRAMAX 1 GM I.M. VIALRAMEDA > SUN PHARMA EGYPT LIMITED71.00 EGP
TRIAXONE 1 GM I.M. VIALTABUK PHARMACEUTICAL MANUFACTURING COMPANY > TABUK PHARMA106.00 EGP
TRIAXONE 1 GM I.V VIALTABUK PHARMACEUTICAL MANUFACTURING COMPANY > TABUK PHARMA106.00 EGP

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.