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• W4386585893 abstract "Figure: rash, secondary syphilisFigureFigureA 20-year-old woman with a history of major depressive disorder presented with a diffuse rash for four days, which started on her forearms and spread to her trunk and thighs. The rash was nonpruritic and painless. She had not used any new medications recently, and had not changed soaps, detergents, or cosmetics. She had no fever, tongue or throat swelling, shortness of breath, nausea, vomiting, diarrhea, or abdominal pain. She also did not have vaginal discharge, vaginal bleeding, oral or vaginal lesions, or dysuria. She had recently been sexually active with one male partner without condom use. She was nontoxic-appearing and afebrile with normal vital signs. She had a diffuse, non-raised, light pink maculopapular rash over her arms and trunk that blanched with pressure. Notably, the rash was also present on both palms. There were no mucosal lesions in her oropharynx. She declined a pelvic examination. Urinalysis showed little blood and trace leukocyte esterase. Rapid HIV screening was negative. Urine gonorrhea and chlamydia testing was pending. What other tests would you order to confirm the diagnosis? What should the treatment be? Find the diagnosis and case discussion on p. 12. Diagnosis: Secondary Syphilis Syphilis is a bacterial infection of growing concern in the United States; rates of reported infections more than doubled between 2000 and 2013. (Morb Mortal Wkly Rep. 2014:63[18]:402; https://bit.ly/3oUJrpE.) The infection is caused by the spirochete Treponema pallidum. It is predominantly sexually acquired, although vertical transmission also occurs in utero or during delivery. The breadth of associated symptoms has led to syphilis being referred to as the great masquerader. The clinical presentation depends on the stage of the disease. In primary syphilis, a painless chancre appears at the point of initial infection a short time after exposure, and typically lasts three to 10 weeks. Secondary syphilis often presents as mucocutaneous lesions and lymphadenopathy four to eight weeks after the chancre has healed. A rash seen in secondary syphilis is often maculopapular, is pale red or pink, and may involve the palms, soles, and scalp. Cutaneous warts, or condylomata lata, may be seen in intertriginous regions. These findings usually resolve within two to six weeks. Systemic symptoms, including a viral-like illness or headache and meningismus, may also occur during this phase. In the late stages of disease (one to 30 years after primary infection), tertiary syphilis can present with a wide range of neurological, cardiovascular, skeletal, and dermatologic findings. Of note, prolonged asymptomatic latent phases may separate each of the stages. (BMJ. 2007; 334[7585]:143; https://bit.ly/3szjCNR.) Sexual activity is the predominant risk factor for syphilis infection, and condom use does not entirely prevent infection. Infections have traditionally been highest among men who have sex with men and sex workers, but recent trends highlight increasing transmission in heterosexual populations in some regions. (BMJ. 2007; 334[7585]:143; https://bit.ly/3szjCNR.) Clinicians are advised to consider the prevalence in their communities for screening and testing. Co-infection with HIV is also common because HIV predisposes patients to syphilis infection, and vice versa. (Sex Transm Dis. 2005;32[5]:265; https://bit.ly/39AJCzX.) The decision to test patients in the ED typically begins with signs and symptoms attributable to syphilis in combination with known risk factors and the local prevalence of the disease. The most common testing strategy involves initial screening with serum non-treponemal tests, such as rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL). Seroconversion may lag two to four weeks behind infection, but these tests are semi-quantitative, and the titer levels can be trended to demonstrate cure. These tests lack sensitivity and specificity, so confirmatory testing via treponemal tests, such as fluorescent treponemal antibody absorption (FTA-ABS) or T. pallidum enzyme immunoassay (TP-EIA), are often used. These are qualitative only, and they will remain positive for life. (JAMA. 2016;315[21]:2321; https://bit.ly/3nLOyXz.) Some have advocated for expanding testing to at-risk asymptomatic ED patients, along with HIV testing, and the development of rapid serologic tests that can be confirmed with RPR may allow for the expansion of this strategy in the future. (Sex Transm Dis. 2019;46[7]:429; https://bit.ly/2LupMOT.) Testing for concomitant HIV and other sexually transmitted infections is advisable. For patients with suspected neurosyphilis (e.g., meningitis, psychosis, paralysis, tabes dorsalis), cerebrospinal fluid (CSF) analysis classically shows elevated CSF protein and lymphocytic pleocytosis. A reactive CSF VDRL is the first step in making the diagnosis of neurosyphilis, but it lacks sensitivity. If suspicion persists despite negative CSF VDRL, the more sensitive (but less specific) CSF FTA-ABS may be used to confirm the diagnosis. (J Neurol Neurosurg Psychiatry. 2004;75[12]:1727; https://bit.ly/3qr88dE.) Treatment strategies depend on the stage of syphilis infection. The preferred treatment of primary, secondary, and early latent syphilis is a single intramuscular dose of penicillin G benzathine 2.4 million units. For tertiary or late latent disease, first-line treatment is penicillin G benzathine 2.4 million units weekly for three weeks. Neurosyphilis, in addition to ocular or otosyphilis, requires intravenous aqueous penicillin G every four hours for 10 to 14 days. (WHO. 2016; https://bit.ly/3nNEWvv.) Treatment may provoke the Jarisch-Herxheimer reaction, a brief, self-limited febrile reaction related to spirochete lysis provoking worsening rash, myalgias, rigors, and headache, and can be managed with antipyretics while continuing antibiotic treatment. RPR titers are followed at six and 12 months to ensure treatment success by a fourfold titer decrease. Ultimately, this patient was found to have a 1:32 RPR titer that was subsequently confirmed with a reactive TP-EIA antibody test after discharge. She was treated with intramuscular penicillin G benzathine 2.4 million units. Repeat RPR titers in six months were planned. Dr. Arnoldis an emergency medicine resident at LAC+USC Medical Center. Follow him on Twitter@EricArnold_. Dr. Burkholderis an assistant professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California. Follow him on Twitter@tayburkholder. Read past Quick Consult columns athttp://bit.ly/EMN-QuickConsult." @default.
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• W4386585893 date "2021-03-01" @default.
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