Case 089: Sexually Transmitted Diseases

PATIENT PRESENTATION

Chief Complaint

“I have been feeling more tired lately along with muscle pain and fevers. I have also noticed a rash on my torso, I’ve tried creams over the counter, but it doesn’t seem to be improving. I’ve also been having increased swelling in my lower extremities over the last few weeks.”

History of Present Illness

KS, a 53-year-old male presents with signs and symptoms consistent with syphilis. Additionally, on physical exam his legs have noticeable swelling. KS past medical history is notable for hypertension. His home medications include amlodipine and lisinopril.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What symptoms does KS have that are consistent with syphilis?

   Hint: See Syphilis in PPP

2. What stage of syphilis does KS have based on his symptoms?

   Hint: See Syphilis in PPP

3. What is the treatment of choice for secondary syphilis?

   Hint: See Syphilis in PPP

4. If this patient were to have a history of severe non-IgE mediated reactions to penicillin in the past, what is an alternative treatment option?

   Hint: Refer to the Center of Disease Control 2021 Sexually Transmitted Infections Treatment Guidelines

5. What is the cause the patient’s notable swelling in the lower extremities?

   Hint: Refer to Amlodipine package insert

FOLLOW-UP

Sexual partners of KS within what duration of the onset of his symptoms would be considered at risk for infection?

Hint: Refer to the Center of Disease Control 2021 Sexually Transmitted Infections Treatment Guidelines

CASE SUMMARY

Global Perspective

Data on substitute regimens for treatment of primary or secondary syphilis in patients with penicillin allergies is currently lacking. In nonpregnant patients, other treatment options include doxycycline 100mg PO BID for 14 days or tetracycline 500mg PO QID for 14 days. Some studies in addition to biologic/pharmacologic characteristics suggests that ceftriaxone 1g IV or IM for 10 days may be another option—although the exact dose/duration has not been confirmed. The CDC recommends against the use of azithromycin for syphilis given current resistance patterns of this pathogen. (Workowski et al, 2021).

Key References