Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
Herpes and chancroid lesions are typically painful. Herpetic lesions start as small
(2-3 mm) grouped vesicles which rapidly from shallow ulcers. Ulcers of chancroid are deep
with irregular, non heaped up margins that appear punched out and often have pus in the
base. Lesions of primary syphilis with one or more ulcers known as chancres are not
painful. Calymmatobacterium granulomatis manifests as a painless, destructive ulcer
characterized by exuberant tissue formation and healing with scarring. The primary lesion
of lymphogranuloma venereum is usually trivial and not noted. Chancroid and LGV are
associated with fluctuant inguinal lymphadenopathy.
Answer 2
Sex with men, use of barrier contraception, drug use including heroin and cocaine.
Answer 3
No. Nontreponemal serologic tests for syphilis are positive in only approximately
60-70% of individuals at the time the chancre first appears. A nonreactive test does not
rule out syphilis in such patients. Nontreponemal serologic tests (RPR and VDRL) should be
confirmed with a specific treponemal test such as the FTA-ABS or MHA-TP.
Answer 4
T. pallidum is a spirochete that may be visualized by reflected light using
dark-field microscopy. A drop of fluid can often be expressed by compressing the chancre
between gloved index finger and thumb. The organism can also be identified from clinical
specimens including tissue biopsies by silver staining or by direct immunofluorescence.
Answer 5
All patients with early syphilis should undergo counseling and testing for HIV.
Answer 6
Unless the patient is hypersensitive, penicillin remains the drug of choice for all
stages of syphilis.
Answer 7
Benzathine penicillin G at 2.4 million units IM in one treatment is the dosage to
be given. In patients with allergy to penicillin that is not manifested by anaphylaxis,
cetriaxone 1.0 g for 8-10 days may be a suitable alternative; however clinical experience
is sparse. In penicillin allergy, one may use doxycycline, 100 mg PO bid for 2 weeks, or
tetracycline, 500 mg PO q.i.d. for 2 weeks.
Answer 8
Persons exposed within the 90 days preceding the diagnosis of early syphilis should
be evaluated and treated presumptively. Persons exposed greater than 90 days before should
be evaluated and undergo serologic testing.