Cagayan Valley Medical Center

Tuguegarao City, Cagayan

CASE
PRESENTATION
Baculi, Ruth Vivian
Canaoay, Janela
Guzman, Hennie Dee
Malawis, April
Pagud, Melowin
 TABLE OF CONTENTS

PHYSICAL
HISTORY EXAMINATION
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DIFFERENTIAL CASE
DIAGNOSIS DISCUSSION
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 General Data
Name: HD
Age: 19
Gender: Male
Status: Single
Birthdate: 01/30/2004
Address: Malamag West, Tumauini, Isabela
Religion: Roman Catholic

Informant: Patient
Reliability: 85%
Date and Time: October 10, 2023, 1:00 PM
Chief Complaint
Perianal Lesions
 History of Present Illness

6 weeks PTC
● Multiple, localized, circular, brown, small lesions on his perianal area
○ (+) pain(3/10) when sitting down
○ (+) pruritic
○ (-) pus
○ (-) bleeding
● Associated symptoms:
○ rashes, pink to brown macules on both palms and soles.
○ Painless ulcer on his penile area
● (-) fever, (-) dysuria, (-) penile discharge, (-) abdomino-pelvic pain,
(-) weight loss
● No medications taken, no consultation done.
 History of Present Illness
3 weeks PTC
● Enlarging multiple, circular, localized, brown lesions on his perianal area.
○ Non-pruritic
○ Painless
● Sought consult in a Private Family Medicine Clinic, Tumauini
○ Ciprofloxacin 500mg, 1 tab BID
○ Celecoxib 200mg.
● RPR/VDRL and HIV tests are requested

5 days PTC
● Reactive RPR/VDRL, hence referral to Family Medicine OPD
 Review of Systems
General (-) easy fatigability, (-) loss of appetite

Integumentary (-) pallor, (-) jaundice

CNS (-) loss of consciousness, (-) seizures, (-) lightheadedness

HEENT (-) headache, (-) dizziness

Cardiovascular (-) palpitations, (-) orthopnea

Respiratory (-) PND, (-) shortness of breath

Gastrointestinal (-) constipation, (-) diarrhea, (-)nausea/vomiting

Genitourinary (-) anuria, (-) oliguria

Endocrine (-) polydipsia, (-) polyuria, (-) polyphagia, (-) tremor

Musculoskeletal (-) myalgia, (-) arthralgia

 Past Medical History
No HTN, DM, Heart disease, Liver disease, Kidney disease, Liver disease, Asthma, PTB

No known allergies to food/drugs

No recent history of hospitalization

 Family History
PATERNAL MATERNAL

HTN (-) (-)

DM (-) (-)

Heart Disease (-) (-)

Liver Disease (-) (-)

Thyroid disease (-) (-)

Asthma (-) (-)

PTB (-) (-)

Family Genogram
Personal and Social History
Ongoing College Student

Smoker using Vape: started February 2023

Alcoholic beverage drinker (started drinking 2022, 9 shot glass of emperador)

AUDIT C:
2-4x a week: 2
7-9 standard drinks: 3
6 or more weekly: 3
Total: 8
Alcohol Misuse

Denies Illicit Drug use

Diet: 3 meals per day (2 cups of rice + mostly Fish + Vegetables + occ. Meat

ADL: Volleyball
 Sexual History
1 year prior to consult
(+) alleged sexual abused thru his anal canal by a homosexual male

Sexual orientation Heterosexual

Partner No girlfriend

Practices Denies other sexual history

 PHYSICAL
EXAMINATION
 The patient is conscious, coherent, ambulatory, and not in cardiorespiratory
General Survey distress.

VITAL SIGNS

Blood Pressure 120/80 mmHg ANTHROPOMETRIC

Pulse Rate 85 bpm Height: 175cm

Respiratory Rate 18cpm Weight: 54.1kg

Temperature 36.1deg C Body Mass Index: 17.67 (Underweight)

Oxygen Sat at Room Air 99% Ideal Body Weight: 56.6-70kg

 Physical Examination
SKIN (-) pallor, (-) cyanosis, (-) jaundice, good skin turgor

HEENT Head: normocephalic, (-) scalp lesion

Eyes: anicteric sclera, pink palpebral conjunctiva, pupil reactive to
light and accommodation
Ears: (-) deformity, no ear discharges, clear ear canal
Nose: (-)lesions, (-) discharge, nasal septum midline
Throat/Oral Cavity: tongue and uvula midline, (-) ulceration, (-)
bleeding

NECK Neck moves freely, no cervical lymphadenopathy, trachea midline,

thyroid not enlarged
 Physical Examination
CHEST & LUNGS Inspection: No retractions
Palpation: Symmetric chest expansion
Percussion: Resonant
Auscultation: Clear breath sounds

CARDIOVASCULAR Inspection: Adynamic precordium

Palpation: (-) thrills, (-) heaves
Auscultation: Normal rate, regular rhythm, distinct S1 and S2, (-)
murmur

ABDOMEN Inspection: flat, no mucocutaneous rashes

Auscultation: Normoactive bowel sounds
Palpation: No organomegaly
Percussion: Tympanic on hollow organs, dull on solid organs
GENITOURINARY Inspection: Grossly male, (-) edema, (-) discharge
● Multiple, localized, circular, pinkish, moist,
cauliflower-like, painless verrucous papules on
perianal area.
● Noted Healed Ulcer (<5cm in diameter) on his
Penile area
Palpation: (-) swollen glands, (-) tenderness

EXTREMITIES Inspection: (-) gross deformities, (-) edema, (-) nail

clubbing
● Multiple, localized, circular, brown, macular
healed lesions on his palms, and soles of his feet,
bilateral
Neurological Examination
CN I Able to smell

CN II Pupils equally reactive to light and accommodation

CN III, IV, VI Intact extraocular muscles

CN V Positive corneal reflex

CN VII No facial asymmetry

CN VIII Normal hearing

CN IX, X Positive gag reflex

CN XI Able to shrug shoulders

CN XII Tongue at midline protrusion

Neurological Examination
MOTOR 5/5 on upper and lower extremities

SENSORY Withdraws to stimulus in all extremities

 SALIENT FEATURES
● 19 y/o
● Male
● Painless ulcer
● Macular rash on palms and soles
● Presence of scars
● Sexual history (MSM - men who have sex with
men)
● RPR VDRL reactive
DIFFERENTIAL
DIAGNOSIS
 Herpes Simplex Virus
HSV belongs to the alpha herpesvirus group. HSV are ubiquitous, host-adapted
pathogens that cause a wide variety of disease. Two types exist: herpes simplex
virus type 1 (HSV-1) and type 2 (HSV-2).

RULE IN RULE OUT

● 19 y/o ● Female
● Macular rash on palms and ● Painful ulcer
soles ● No scar
● MSM ● Prodrome period
● Minimal clear Discharge
 Chancroid
Chancroid is a sexually transmitted infection caused by the bacteria
Haemophilus ducreyi, which causes painful genital sores. Chancroid is a
common cause of genital ulcers in areas of Asia, Africa, and the Caribbean.

RULE IN RULE OUT

● 19 y/o ● Painful ulcer
● Male ● Inguinal lymphadenitis
● Presence of scar ● Discharge
● MSM
 LYMPHOGRANULOMA VENEREUM
STI caused by L serovars of Chlamydia trachomatis. Peak incidence occurs in 15 to 40 y/o
and men are 6x more likely than women to manifest clinical infection. It is contracted by
direct contact with infectious secretions through any type of unprotected intercourse.

RULE IN RULE OUT

● 19 y/o ● Inguinal and/or femoral lymph node

● MSM involvement
● Painless ulcer on penile area ● “Groove sign”
● Macular rash on palms and soles
 HIV

RULE IN RULE OUT

● 19 y/o
● MSM HIV RAPID TEST result (pending)
● Asymptomatic presentation
● Macular rash on palms and soles
● Penile ulcer
 SYPHILIS
Chronic systemic infection caused by Treponema pallidum subspecies pallidum, is
characterized by episodes of active disease interrupted by periods of latency.

RULE IN RULE OUT

● 19 y/o
● MSM
● Characteristic Chancre Lesions: HIGHLY ENTERTAINED
➔Painless ulcer on penile area
➔Cauliflower-like, painless
verrucous papules on perineal area.
● Macular rash on palms and soles

RPR/VDRL: REACTIVE
 IMPRESSION

Secondary Syphilis
 PLAN
● Diet: Pinggang Pinoy
● Diagnostics: HIV, HBsAg
● Pharmacologic:
○ Penicillin G 2.4 million units IM
 PLAN
● Nonpharmacologic:
○ Secured consent for treatment
○ Emphasized compliance to medications and follow-up
check up
○ Reiterate importance of safe sex practices
○ Advised on proper genital hygiene
○ Advised healthy lifestyle and balanced diet to achieve IBW
of 56.6 to 70 kg
○ TCB once with lab results or anytime if with untoward signs
and symptoms
○ MGH after treatment
 CASE
DISCUSSION
 Syphilis
● a.k.a lues
● A disease caused by the spirochete Treponema pallidum subspecies
pallidum that is almost exclusively sexually transmitted
● The most common and recognizable manifestations are usually cutaneous
● Syphilis passes through 4 distinct clinical phases:
Primary Stage Chancre

Secondary Stage Skin eruptions with or without lymphadenopathy and organ disease

Latent period absence of signs or symptoms of disease, with only reactive serologic tests
as evidence of infection

Tertiary stage cutaneous, neurologic, or cardiovascular manifestations.

● Neurosyphilis and ophthalmic syphilis can occur at any stage.

 Epidemiology
● Reactivity rate of 1.9% (2022)
● 2.1 cases per 100,000 population in the United States.
● Primarily driven by increasing cases among gay, bisexual, and
other men who have sex with men (MSM).
○ Of 19,999 reported cases of primary and secondary syphilis in
2014, 12,226 (61.1%) were among MSM and 3,407 (17.0%) were
among men without information about the gender of the sex
partner
● Rates of primary and secondary syphilis nationwide are highest in
persons 20-29 years old.
● Internationally, an estimated 12 million new cases of syphilis
occur.
 Risk Factors
Behavioural Risk Factors
● Barrierless sexual activity
involving contact with oral,
genital, or anal mucosa
● Having multiple sexual
partners
● Sexual contact with a known
case of syphilis or other STBBI
● Substance use
Epidemiological Risk Factors
● Previous syphilis infection or
other STBBI
● HIV infection
● Population groups and/or
communities experiencing high
prevalence of syphilis (and
other STBBI)
● Having experienced
homelessness and/or street
involvement
 Diagnostics
● Direct detection of T. pallidum
○ Darkfield Microscopy
○ Direct Fluorescence Antibody Test
○ Molecular Tests
● Serology
○ Non-Treponemal Serologic Tests
○ Treponemal Serologic Tests
 Direct detection of T. pallidum
● DARKFIELD MICROSCOPY
○ Diagnostic test of choice in chancres,
moist lesions of secondary syphilis
(condylomata lata and mucous patches),
and the discharge from rhinitis in
congenital syphilis.
○ Often be positive before serologic tests
become reactive.
○ Cannot be used to test oral lesions
○ Sensitivity is approximately 74% to 79%
but declines as minutes elapse
○ Motile (corkscrew motility), spiral-shaped
bacterium
 Direct detection of T. pallidum
● DIRECT FLUORESCENCE ANTIBODY TEST
○ The lesional exudate is smeared on a glass slide and stained
with fluorescein-labeled anti–T. pallidum immunoglobulin
○ Oral or anal lesions can be examined
○ Sensitivity is 73% to 100%
● MOLECULAR TESTS
○ PCR-based methods have been used to detect T. pallidum
DNA from lesions in research settings.
 Serology
● NONTREPONEMAL SEROLOGIC TESTS
○ VDRL and rapid plasma reagin (RPR) tests
○ begin to become reactive 4-5 weeks after infection, with 100%
sensitivity by approximately 12 weeks
○ revert to nonreactive in 25%-30% of cases during late latent
syphilis
○ Results can be qualitative or quantitative
■ Qualitative - reactive/nonreactive
■ Quantitative - serial dilutions of serum by a factor of 2;
the reported titer represents the most dilute sample that
gives a reactive result
○ Treatment success is defined serologically as a fourfold (two-
dilution) decline in nontreponemal test titer
.
 Serology
● NONTREPONEMAL SEROLOGIC TESTS
○ Persons treated for primary syphilis
■ become nonreactive in 60% by 4 months
○ Persons treated for secondary syphilis
■ become nonreactive 12-24 months after treatment
■ in some cases, nontreponemal tests may remain reactive
in low titers for up to 5 years or longer, or it can also
persist at a low titer for long periods, and sometimes for
life
○ Patients who fail to achieve a fourfold decline in titer, as well
as those who have adequate serologic decline but whose
nontreponemal test titers do not become undetectable, have
been referred to as serofast
.
 Serology
● TREPONEMAL SEROLOGIC TESTS
1. T. pallidum particle agglutination (TPPA) test
2. Microhemagglutination assay for T. pallidum (MHA-TP)
3. Fluorescent treponemal antibody absorption assay (FTA-ABS)
4. T. pallidum hemagglutination test (TPHA)
5. Various treponemal enzyme immunoassays (EIAs) and
immunochemiluminescence assays.
○ These tests use whole or fragments of T. pallidum as antigen
and detect the presence of antibodies to T. pallidum
○ more cumbersome to perform but have greater sensitivity in
the primary and late stages and slightly higher specificity
○ a reactive nontreponemal test result followed by a reactive
treponemal test result confirms a diagnosis of syphilis.
 Management
Penicillin G
- administered parenterally,is the preferred drug
for treating patients in all stages of syphilis
- only therapy with documented efficacy for
syphilis during pregnancy
 Management
Jarisch-Herxheimer Reaction

- an acute febrile reaction

frequently accompanied by
headache, myalgia, and fever
that can occur within the first 24
hours after the initiation of any
syphilis therapy
- Antipyretics
 Management
Management of Sex Partners

1. Had sexual contact with a person who receives a diagnosis of primary,

secondary, or early latent syphilis <90 days before the diagnosis =
treated presumptively for early syphilis, even if serologic test results are
negative
2. Had sexual contact with a person who receives a diagnosis of primary,
secondary, or early latent syphilis >90 days before the diagnosis =
treated presumptively for early syphilis if serologic test results are not
immediately available and the opportunity for follow-up is uncertain.
- serologic tests are negative = no treatment
- serologic tests are positive= treatment
 Management
Management of Sex Partners
3. Certain areas, health departments recommend notification and presumptive treatment of sex
partners of persons with syphilis of unknown duration who have high nontreponemal serologic test
titers = managed as if the index patient had early syphilis.
4. Long-term sex partners of persons who have late latent syphilis should be evaluated clinically
and serologically for syphilis and treated on the basis of the evaluation’s findings.
5. Considered at risk for infection and should be confidentially notified of the exposure and need for
evaluation:

- partners who have had sexual contact

- within 3 months plus the duration of symptoms for persons who receive a diagnosis of
primary syphilis
- within 6 months plus duration of symptoms for those with secondary syphilis
- within 1 year for persons with early latent syphilis.
 Management
Primary and Secondary Syphilis

Adults: Benzathine penicillin G 2.4 million units IM in a single dose

Infants and Children: Benzathine penicillin G 50,000 units/kg body weight IM, up to the adult dose of 2.4 million
units in a single dose

❖ All persons who have primary and secondary syphilis should be tested for HIV at
the time of diagnosis and treatment.
❖ CSF analysis- have syphilis and symptoms or signs indicating neurologic disease
❖ cranial nerve examination and ocular slit-lamp and ophthalmologic examinations-
symptoms or signs of ocular syphil
 Management
Primary and Secondary Syphilis
Follow up:

❖ Clinical and serologic evaluation should be performed at 6 and 12 months after

treatment
❖ Reinfected or experienced treatment failure
➢ signs or symptoms that persist or recur and those with at least a fourfold
increase in nontreponemal test titer persisting for >2 week
❖ Treatment failure
➢ Failure of nontreponemal test titers to decrease fourfold within 12 months
after therapy for primary or secondary syphilis

Retreatment: weekly injections of benzathine penicillin G 2.4 million units IM for 3 wks is recommended, unless CSF
examination indicates that neurosyphilis is present
 Management
Primary and Secondary Syphilis
Penicillin allergy:

❖ Non pregnant

Doxycycline (100 mg orally 2 times/day for 14 days OR Tetracycline (500 mg orally 4 times/day for 14 day OR ceftriaxone
(1 g daily either IM or IV for 10 days)

❖ Non pregnant
➢ desensitized and treated with penicillin G
➢ Skin testing or oral graded penicillin dose challenge might be helpful in
identifying women at risk for acute allergic reactions
 Management
Latent Syphilis

Early latent syphilis: Benzathine penicillin G 2.4 million units IM in a single dose

Late latent syphilis: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million
units IM each at 1-week intervals

Penicillin allergy: Doxycycline (100mg/tab BID) OR Tetracycline (500mg/tab QID) each for 28 days

❖ All persons who have latent syphilis should be tested for HIV at the time
of diagnosis or treatment.
❖ Diagnosis of latent syphilis and have neurologic or ocular signs and
symptoms should be evaluated for neurosyphilis, ocular syphilis, or
otosyphilis
 Management
Latent Syphilis

Follow up:

❖ Quantitative nontreponemal serologic tests

➢ repeated at 6, 12, and 24 months
❖ Reinfected or experienced treatment failure
➢ at least a fourfold sustained increase in nontreponemal test titer
persisting for >2 weeks or who experienced signs or symptoms
attributable to primary or secondary syphilis
 Management
Tertiary Syphilis

With normal CSF examination: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4
million units IM each at 1-week intervals

❖ All persons who have tertiary syphilis should receive a CSF examination before
therapy is initiated and have an HIV test.
❖ Pregnant women who are allergic to penicillin should be desensitized and
treated with penicillin G.
 Management
Neurosyphilis, Ocular Syphilis, and Otosyphilis

Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or
continuous infusion for 10-14 days

If compliance with therapy can be ensured, the following alternative regimen might be considered:

Procaine penicillin G 2.4 million units IM once daily OR Probenecid 500 mg orally 4 times/day, both for 10–14
days

❖ All persons who have neurosyphilis, ocular syphilis, or otosyphilis should

be tested for HIV at the time of diagnosis
❖ Immunocompetent persons and persons with HIV infection who are on
effective ART, normalization of the serum RPR titer predicts normalization
of abnormal CSF parameters after neurosyphilis treatment.
 Prevention
❖ “Partner services” - to a continuum of clinical evaluation, counseling,
diagnostic testing, and treatment designed to increase the number of
infected persons brought to treatment and to reduce transmission
among sexual networks
❖ Use of Barrier Contraceptives (Condom)
❖ Abstinence and Reduction of Number of Sex Partners
❖ Partner-based interventions include partner notification
Thank you!