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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.
“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.
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 nausea, no vomiting, and consistent diarrhea