Case #64: The man with generalised rash
This 24-year-old man presents with generalised rash of 5 days duration. There is no history of fever or URTI symptoms or joint pains. The rash are present on predominantly on his limbs, palms, soles, abdomen and genitalia. The rash are neither painful nor itchy. He was diagnosed with HIV + 6 months earlier while undergoing an annual medical check up but is not on HAART as his CD4 is >600 cells/uL. He admits to engaging in MSM activities. On examination, other than the rash, he has some ulcers in the oral mucosa.
Below are his pictures:
Questions:
1. What is the most likely diagnosis?
2. How will you confirm the diagnosis?
3. Once the diagnosis is confirmed, what bedside procedure will you offer this man before starting treatment?
Mon, 291208 @ 0700
Sorry, I might sound stupid.
But,
You mean that the intra-dermal sensitivity test for penicillin is no longer done, even to prevent anaphylactic shock in those who are allergic to it?
or they cover it with steriods? (I thought the life-saving drug for anaphylactic shock is adrenaline?)
Answers:
1. Secondary syphilis ~ as characterised by typical rash and oral ulcers (not shown).
2. VDRL – for screening as well as prognostcic marker. Successful treatment should see a 4-fold-decrease in the titer within 6-12 months. A rise would indicate treatment failure, antibiotic resistance or a new exposure. TPHA or FTA-ABS for confirmation.
3. Lumbar puncture. A HIV+ person has 3x the risk of asymptomatic neurosyphilis compared to a non-HIV+ person with syphilis. CSF for VDRL is sent. The result will differentiate between secondary syphilis and tertiary syphilis and this would influence the choice of antibiotics, route of administration, and duration of therapy.
Kudos go to TFTD, iriqci, CK (though viewing of spirocheates in the CSF is not done) and Conmen who was the first to hit the jackpot!
Sensitivity test for penicillin is no longer done and has been relegated to the archives of internal medicine.
Well done.
1. Secondary syphilis
2. TPHA/FTA-ABS
3. Lumbar puncture to rule out neuro involvement. HIV patient may have asymptomatic neurosyphilis.
1. 2′ syphilis , considering the character and location of the maculopapular rash
2. Serological test Enzyme Immunoassay(EIA) and RPR or VDRL.
Take sample from lesion to observe under dark-field microscopy(corkscrew + motile)
3. Penicillin allergy skin test
Welcome aboard, Chong_86!
New here.
1. Secondary syphilis –
painless maculopapular rashes over the genitalia, abdomen, and extremities
engaged in MSM activities
no history of fever or any other constitutional symptoms, as the primary stage might be asymptomatic
oral ulcers : some patients with secondary syphilis might present with atypical oral ulceration
2. Investigations
a) Non-specific serologic test
VDRL or RPR to detect reagin antibodies
b) Specific serologic test
FTA-ABS or TPHA
3. Actually I’m not sure whether it’s LP or hypersensitivity test.
1. Secondary syphilis – because it develops few months later after infection, maculopapular rash with absence of subjective feelings, progress of lesions without fever.
2. Wassermann’s reaction and microscopy
3. LP
PS: Besides the above complaints, did the patient asked whether he could marry or not? Hope he doesnt or else you will need to become marriage counsellor.
oh, tat means LP is the bedside test la.. erm
Most likely diagnosis: secondary syphilis in view of history of MSM activity history & history of HIV positive, clinical findings of generalized maculopapular rash including on the palms & soles with oral ulcers.
RPR/VDRL for screening; TPHA/FTA-ABS for confirmation of diagnosis. Definitive diagnosis can be established with scrapings of the oral ulcers to view for spirochetes of Treponema Pallidum under darkfield microscope.
Bedside test: Lumbar puncture & viewing the CSF under darkfield for spirochetes as the involvement is up to 30% in secondary syphilis.
*Jarisch-Herxheimer is self limiting & usually resolves by itself within 6 hours & is treated symptomatically. No need for antibiotic testing.
1. As mentioned.
2. RPR/VDRL, TPHA
3. Lumbar pucture.
actually i was thinking acute retroviral syndrome. But as the seroconversion has occurred, he shouldn’t have it….
Actually i’m guessing, hopefully i’m right.
1. Secondary syphilis (common STD)
2. VDRL and FTA
3. Hypersensitivity test
According to my 2nd year lecture, hypersensitivity test is not necessary as steroid is available to overcome the Jarisch-Herxheimer reaction. we just need to observe the patient closely for 24 hours after start on the medication.
…. not sure….
My humble opinion,
Questions:
1. What is the most likely diagnosis?
Secondary syphilis
2. How will you confirm the diagnosis?
Syhphilis ELISA IgG and IgM, TPHA
3. Once the diagnosis is confirmed, what bedside procedure will you offer this man before starting treatment?
I think is to test the hypersensitivity for Antibiotic of choice, IM procaine benzypenicillin cuz will evoke a reaction named after Jarisch-Herxheimer…
To be frank I am not really sure of the diagnosis… this is what I think most likely to be…
this individual present with a generalised maculopapular rash…
1. I would be thinking of reactivation of Varicella zoster in this individual
2. Probably scraping of the lesion and using histochemical or PCR to confirm the virus presence and do a CXR and LP to rule out any respiratory (varicella pneumonia) and neurological problem
3. ehhh… isolation? since it is contagious…. rx with antiviral – aciclovir