1. A Man with a Faint Rash The 5-Minute STI Clinical Case Study

2. Case History 30 year-old gay man complaining of a faint, non- itching rash for >4 weeks Took left-over amoxicillin for sore throat about 1 month ago – however, pt. does not have a prior history of penicillin allergy No neurological symptoms or other physical complaints

3. Case History -Continued Sexual and STI History –2 partners in past 6 months: One steady partner One occasional partner (about 3 months ago) –Protected receptive and insertive anal sex with steady partner only –Unprotected oral sex with steady and occasional partners –No history of genital/rectal sores –Rectal gonorrhea and chlamydia > 1 year ago –History of primary syphilis – treated 4 years ago with 2.4 MU LAB –Most recent RPR: NR (14 months ago; this clinic –HIV: negative (14 months ago; this clinic)

4. Physical Exam Faint erythematous macular rash trunk and extremities Soles of feet involved, but palms of hands are not No excoriations or scratch marks noted No penile or anal lesions observed Neurological exam: normal

10. Question 1 What laboratory test would be the least useful in this case? a)Qualitative (stat) RPR b)Quantitative RPR c)Treponemal test (TPPA or FTA-abs) d)HIV rapid test e)HIV viral load

11. Stat Lab Results Qualitative RPR reactive: ++++ HIV Rapid Test: Positive

12. Question 2 Based on our knowledge so far, what is the most likely diagnosis? a)Acute HIV Infection b)Drug rash c)Secondary syphilis d)Scabies

13. Question 3 You decide to treat the patient for secondary syphilis – what do the CDC treatment guidelines recommend: a)LAB 2.4 MU i.m. now and refer to HIV care b)LAB 2.4 MU i.m. now and once a week for 2 subsequent weeks + refer to HIV care c)Patient should undergo LP before treatment is initiated d)Refer to HIV care as treatment will depend on HIV viral load and CD4 count

14. Question 4 Regarding the patient’s follow up – which is a CDC recommendation? a)Patient should return for follow-up at 1 and 2 weeks for additional treatment b)Serological follow-up should be more frequent than in HIV negative patients c)Follow-up should include a neurological work-up and LP to exclude neurosyphilis

15. Disclaimer Copyright case study and clinical photos: –Dr. Kees Rietmeijer, STD Control Program, Denver Public Health Department Individual slides can be used for educational purposes with reference to source and/or inclusion of the DMHC logo