Syphilis: The Great Masquerader

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the Januray 2026 Emergency Medicine Practice article, Emergency Department Diagnosis and Management of Patients With Syphilis

Syphilis cases have surged 42% in the US, making it critical for emergency physicians to recognize and treat this "great masquerader." In this episode, hosts Sam Ashoo and Dr. T.R. Eckler break down the January 2026 Emergency Medicine Practice article on syphilis diagnosis and management. They cover the rising prevalence in high-risk populations, the four clinical stages (primary, secondary, latent, and tertiary), special presentations like neurosyphilis and congenital syphilis, and practical diagnostic approaches. With a national penicillin shortage, they discuss alternative treatment options including doxycycline and post-exposure prophylaxis. The conversation also addresses the dark history of the Tuskegee Study and its lasting impact on medical ethics. Whether you're seeing more cases in your ED or want to sharpen your diagnostic skills, this episode provides actionable insights for frontline providers.

Timestamps

00:00 - Introduction and welcome

02:15 - Epidemiology: Why syphilis cases are surging

06:30 - High-risk populations and screening recommendations

10:45 - Pathophysiology of Treponema pallidum

14:20 - Clinical stages: Primary syphilis and the chancre

18:40 - Secondary syphilis: The classic rash presentation

24:15 - Tertiary syphilis and cardiac complications

28:50 - Neurosyphilis: Meningitis, cranial nerve deficits, and stroke-like symptoms

34:10 - Congenital syphilis: Rising cases and screening importance

38:25 - Ocular and otosyphilis presentations

42:00 - Diagnostic approach: VDRL, RPR, and treponemal tests

47:30 - Interpreting titers and fourfold changes

51:15 - Dark field microscopy ("the coolest lab job")

54:40 - Treatment: Benzathine penicillin G and the national shortage

59:20 - Alternative treatments: Doxycycline and ceftriaxone

1:03:45 - Jarisch-Herxheimer reaction explained

1:07:30 - Partner management and contact tracing

1:11:00 - Post-exposure prophylaxis: The "Doxy-PEP" protocol

1:15:20 - Historical context: Tuskegee Study and Guatemala experiments

1:22:45 - Emerging therapies and future directions

1:26:10 - Five key practice-changing takeaways

1:29:00 - Closing remarks and CME information

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