Case Studies

Case 6: Secondary syphilis

A 42-year-old MSM attends the SRH clinic for an STI screen. He was last tested for STIs 12 months ago but has been working abroad since then in Russia. He has had multiple sexual partners while abroad in the past 3 months. His last sexual contact was 3 weeks ago. All his sexual contact has been with casual male partners. He has had receptive and insertive anal sex but always uses condoms for this. He has had insertive and receptive oral sex but doesn’t always use a barrier method for this. On clinical history taking he says that he has been feeling quite tired recently but had put this down to jetlag. He also asks if you could look at a rash he has got on his hands as he has been unable to see his GP about it. He wonders if it is dermatitis due to using different soaps while living abroad.

• 1. What screening tests would you offer this man?

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  Correct answer: NAAT test for gonorrhoea and chlamydia from urethra (urine), rectum and pharynx

  Syphilis and HIV serology and Hepatitis B screening (if not already vaccinated).

• 2. Given this man’s clinical history, what concerns do you have about possible undiagnosed infections?

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  Correct answer: He has had unprotected oral sex with multiple partners abroad. Russia is a region considered high risk for HIV and syphilis infection. His fatigue and rash could be symptoms of an HIV seroconversion illness. They could also be indicators of secondary syphilis. Both infections can co-exist.

• 3. Is an examination indicated and if so what would that entail?

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  Correct answer: Yes he should undergo a thorough clinical examination. Particular attention should be given to examining the genitals, skin and lymph nodes looking for signs of secondary syphilis. The oral cavity should be inspected for mucous membrane lesions. The nature and extent of the rash should be documented. A maculopapular rash and mucosal ulceration can also occur in primary HIV infection.

• 4. Your examination reveals a maculopapular rash on the palms of his hands. He has generalised lymphadenopathy, but otherwise the clinical examination is normal. What is your working diagnosis and is there anything which can be done to expedite confirmation?

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  Correct answer: Secondary syphilis is the most likely diagnosis but HIV infection still needs to be excluded in this man. Rapid point of care testing (for syphilis and HIV) would be useful in this situation to confirm the clinical suspicion of secondary syphilis and prevent a delay in initiating treatment. These tests do not replace serology which should also be undertaken.

• 5. The man is diagnosed with secondary syphilis. His initial HIV test is negative but he understands that he will need a repeat test out with the window period. He is treated with benzathine penicillin IM. Following his first injection he phones the clinic to say he is feeling unwell. He says he has a temperature and a headache. What is the most likely cause of this and how do you manage it?

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  Correct answer: It is likely to be a Jarisch–Herxheimer reaction, which is common at the start of antibiotic treatment in secondary syphilis. It is due to the release of endotoxin when large numbers of organisms are killed by antibiotics. It is usually mild and resolves within 24 hours. Supportive treatment is recommended e.g. bed rest and antipyretics. Occasionally the reaction can be severe and require treatment with corticosteroids.