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Patient Case: Syphilis

Patient Case: Syphilis

Discussion

Chief Complaint: “I noticed a painless sore on my genitals two weeks ago, and now I have a rash on my hands and feet.”

History of Present Illness:
A 28-year-old man presents to the clinic with concerns about a painless genital sore that appeared three weeks ago but resolved on its own. However, over the past week, he has developed a widespread rash, particularly on his palms and soles, along with mild fatigue and swollen lymph nodes.

He reports unprotected sexual intercourse with multiple partners in the past six months but denies a history of similar symptoms. He has no known allergies or previous sexually transmitted infections (STIs).

Past Medical History:

  • No known chronic illnesses
  • No history of HIV or other STIs

Physical Examination:

  • Skin: Non-itchy maculopapular rash on the trunk, palms, and soles
  • Lymph nodes: Generalized nontender lymphadenopathy
  • Genital exam: No active ulcers, but a faint scar at the previous sore site
  • Neurologic exam: Normal

Diagnosis:
The patient’s history and physical findings are highly suggestive of secondary syphilis, which follows the primary stage characterized by a painless chancre (ulcer).

Diagnostic Tests:

  • Rapid Plasma Reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test: Positive
  • Treponemal-specific test (e.g., FTA-ABS or TPPA): Positive
  • HIV testing: Recommended due to high-risk behavior

Management Plan:

  • First-line treatment: Single-dose intramuscular benzathine penicillin G (2.4 million units)
  • Education and prevention:
    • Partner notification and testing
    • Safe sex practices (consistent condom use)
    • Follow-up RPR testing to monitor treatment response
  • Monitor for complications:
    • Neurological or cardiovascular symptoms (late syphilis)
    • Jarisch-Herxheimer reaction (a transient flu-like reaction after antibiotic treatment)

The patient is advised to abstain from sexual activity until the infection is fully treated and his partners have been tested.

Questions
  1. What is the most likely diagnosis in this patient?
    a) Gonorrhea
    b) Primary syphilis
    c) Secondary syphilis
    d) Herpes simplex virus (HSV) infection
  2. Which of the following is a characteristic finding in secondary syphilis?
    a) Painful genital ulcers
    b) Painless chancre
    c) Maculopapular rash on the palms and soles
    d) Vesicular rash in a dermatomal pattern
  3. What is the first-line treatment for this patient?
    a) Oral doxycycline for 7 days
    b) Single-dose intramuscular benzathine penicillin G
    c) Oral acyclovir for 10 days
    d) Ceftriaxone 250 mg IM
  4. Which of the following tests is used to confirm syphilis after a positive RPR test?
    a) ELISA for chlamydia
    b) HIV antibody test
    c) Fluorescent treponemal antibody absorption (FTA-ABS)
    d) Gram stain of the ulcer
Reveal answers

Answers

  1. (c) Secondary syphilis – This patient initially had a painless genital ulcer (chancre), which resolved, followed by a widespread rash on the palms and soles, a classic sign of secondary syphilis.
  2. (c) Maculopapular rash on the palms and soles – Secondary syphilis presents with a non-itchy rash, which often involves the palms and soles, a key distinguishing feature from other skin conditions.
  3. (b) Single-dose intramuscular benzathine penicillin G – The gold standard treatment for syphilis at all stages is penicillin G, administered intramuscularly. Doxycycline is an alternative for penicillin-allergic patients.
  4. (c) Fluorescent treponemal antibody absorption (FTA-ABS) – After a positive RPR or VDRL test, a treponemal-specific test like FTA-ABS or TPPA is used to confirm syphilis diagnosis.

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