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Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy. Email User Services (userservices@mhprofessional.com) for more information.
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After completing this case study, the reader should be able to:
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Discuss the diagnosis of syphilis and differentiate among the temporal stages of the disease.
Develop a pharmacotherapeutic treatment plan individualized for the patient’s stage of syphilis.
Recommend alternate treatment regimens when the primary therapeutic option is contraindicated.
Describe appropriate monitoring, follow-up, and counseling of patients with a syphilitic infection to ensure success of treatment.
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“This rash started 3–4 days ago on my back and stomach. My whole left side has been hurting, and I’ve also been feeling weaker than usual lately.”
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John Rutherford, a 27-year-old man with a past medical history of HIV on HAART, presents with left upper quadrant/left back/left side pain and a diffuse rash. He states the rash started 3–4 days ago, and is mostly on his chest, abdomen, and arms. He also has seven macules on his scalp. The rash is nonpainful and nonpruritic, except on his scalp where he has developed a few scabs from itching; no drainage from any lesions is noted. He also has been having some chest pain that is worse with breathing. He notes nausea, though no vomiting, and reports ongoing nonbloody diarrhea for months. He presents to the ED primarily because of pain in his upper left back that radiates around his left side. His urine is very dark, brownish-red; however, he has no dysuria. The patient also states he has felt weaker than usual for the past few days.
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Both parents with hypertension, still living
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Unemployed
Tobacco 1.5 ppd since early teens
Social alcohol usage (average four drinks per week)
Occasional methamphetamine use—both smoked and injected (with clean needles)
Previous MSM Hx (four partners in last 6 months) with inconsistent use of condoms
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Tenofovir/emtricitabine 300/200 mg PO once daily
Raltegravir 400 mg PO BID
Acetaminophen–hydrocodone 325/5 mg PO Q 6 H PRN
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Constitutional: reports weakness and malaise; denies fever
Eyes: denies vision changes
Ears, nose, and throat: denies sore throat, rhinorrhea, or sinus pressure
Lymphatic: denies lymph node swelling
Respiratory: denies shortness of breath, dyspnea on exertion, or cough
Cardiovascular: reports some chest pain on inspiration
Gastrointestinal: reports intermittent nausea, no vomiting, and consistent diarrhea
Neurologic: denies neuropathy symptoms
Musculoskeletal: reports arthralgias and myalgias
Skin: rash on scalp, abdomen, arms, and legs present
Pain: reports persistent abdominal and left side pain
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