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After completing this case study, the reader should be able to:

  • Discuss the diagnosis of syphilis and differentiate among the temporal stages of the disease.

  • Develop a treatment plan individualized for the patient’s stage of syphilis.

  • Recommend alternative 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.


Chief Complaint

“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.”


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.


Hepatitis B, now immune

HIV diagnosed 6 months ago, on HAART


Both parents with hypertension, still living


Unemployed; cigarette smoking 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


Bictegravir/tenofovir alafenamide/emtricitabine 50/25/200 mg (coformulated tablet) PO once daily

Acetaminophen–hydrocodone 325/5 mg PO Q 6 H PRN




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 ...

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