Snapshot A 41-year-old man presents to the clinic complaining of an intensely pruritic rash over his torso, back, and arms including his palms. He also describes being concerned about patchy hair loss on his scalp as well as the presence of warty growths on his penis. His sexual history is notable for frequent sexual encounters with both male and female partners without the use of condoms. Physical exam is significant for a diffuse, erythematous maculopapular rash, patchy alopecia on his scalp, wart-like white lesions on the base of his penis, and bilateral inguinal lymphadenopathy. VDRL and FTA-ABS were positive. Introduction Classification Treponema pallidum spirochete Epidemiology demographics most common during years of peak sexual activity most new cases occur in men and women aged 20-29 years recent rise in syphilis cases among men who have sex with men (MSM) community co-infection of syphilis with HIV is high location genitourinary tract risk factors unprotected sex IV drug use and needle-sharing Pathogenesis mechanism T. pallidum rapidly penetrates intact mucous membranes or dermal abrasions and enters the lymphatics and blood to cause systemic infection transmission intimate contact with infectious lesions (most common) blood transfusion transplacentally from infected mother to fetus Associated conditions cardiovascular syphilis aneurysm formation neurosyphilis Prognosis favorable prognosis for patients diagnosed with either primary or secondary syphilis 20% of untreated patients with tertiary syphilis die of the disease prognosis for tertiary syphilis depends on the extent of scarring and tissue damage with adequate treatment, 90% of patients with neurosyphilis have a favorable clinical recovery Presentation Primary syphilis painless chancre indurated edge can visualize treponemes in fluid from chancre using dark-field microscopy Secondary syphilis disseminated disease diffuse, maculopapular rash that involves the palms and soles condylomata lata smooth, painless, wart-like white lesions on genitals lymphadenopathy patchy alopecia Tertiary syphilis gummas chronic granulomas aortitis from destruction of the vasa vasorum neurosyphilis tabes dorsalis Argyll Robertson pupil pupil constricts with accommodation but is not reactive to light other symptoms broad-based ataxia positive Romberg stroke without hypertension Congenital syphilis facial abnormalities rhagades (linear scars at angle of mouth) nasal discharge saddle nose notched Hutchinson teeth mulberry molars short maxilla saber shins sensorineural deafness Studies Labs nonspecific serologic testing VDRL (venereal disease research laboratory) RPR (rapid plasma reagent) specific serologic testing FTA-ABS (fluorescent treponemal antibody-absorption) use to confirm diagnosis Microscopy dark-field microscopy visualize motile spirochetes Differential Herpes simplex virus painful genital vesicles and ulcers Haemophilus ducreyi painful genital ulcer with exudate Lymphogranuloma venereum buboes Klebsiella granulomatis beefy red ulcer that bleeds on contact Treatment Medical penicillin IM penicillin for primary or secondary syphilis and early latent syphilis IV penicillin G for late latent syphilis if allergic to penicillin, patient should be desensitized doxycyclin an alternative for treating early and late latent syphilis Complications Jarisch-Herxheimer reaction flu-like syndrome after starting treatment for syphilis due to toxins released by killed T. pallidum Complications of tertiary syphilis aortic insufficiency tabes dorsalis general paresis
QUESTIONS 1 of 8 1 2 3 4 5 6 7 8 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.ID.59) A 26-year-old immigrant from Mexico presents to your clinic for a physical. He tells you that over one year ago, he noticed a lesion on his penis which went away after several weeks. A month later, he noticed a rash appearing on his palms and soles, which lasted several weeks and also resolved on its own. Physical exam is unremarkable and shows no evidence of any rash. VDRL and FTA-ABS are both positive. What is the most appropriate treatment for this patient? Review Topic QID: 103000 1 No treatment is necessary 4% (2/54) 2 Intramuscular (IM) penicillin once 24% (13/54) 3 IM penicillin weekly x 2 weeks 13% (7/54) 4 IM penicillin weekly x 3 weeks 54% (29/54) 5 IM doxycycline weekly x 2 weeks 2% (1/54) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M3.ID.61) A 34-year-old male presented to his family physician with a painless genital ulceration. A diagnosis of primary syphilis was made, and the physician prescribed a treatment course of penicillin. Four hours after taking his first dose of medication, the patient presented to the emergency room with fever, headache, and shortness of breath. Physical examination is performed and vital signs are as follows: T 38.4, HR 106, BP 76/42, RR 20, O2 sat 98%. Which of the following could have prevented this patient's complication? Review Topic QID: 103002 1 Prophylactic acetaminophen 0% (0/2) 2 Avoidance of penicillin 0% (0/2) 3 Coadministration of prednisone 0% (0/2) 4 Inquiring about the patient's medication allergies and consideration of an alternative antibiotic 0% (0/2) 5 There is no known way to prevent this complication; administer supportive care and monitor patient 100% (2/2) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 5