A 42-year-old man comes to the physician because of a dull headache, worsening malaise, neck pain, and sore throat for the last two weeks. He has no other medical problems and is compliant with his annual physical examinations. On further questioning, he recalls recovering from a transient, non-pruritic rash a few months ago that he attributed to his vitamin E supplement. He works as a corporate attorney serving a large number of customers overseas, and returned from a business trip to Thailand two months ago.
His medications include calcium, vitamin D, and occasional green tea tablets. He stopped taking vitamin E shortly after the appearance of the rash. He denies smoking and drinks socially. He experienced an anaphylactic reaction to penicillin as a child.
His vital signs are within normal limits. Examination shows no abnormalities.
Laboratory studies showed a normal complete blood count and metabolic panel. His serum RPR titer is reactive at 1:50 and he has a reactive FTA-ABS. HIV ELISA testing was negative. Head CT is normal.
Cerebral spinal fluid (CSF) analysis is as follows:

Which of the following is the next best step in management?

Question

A 42-year-old man comes to the physician because of a dull headache, worsening malaise, neck pain, and sore throat for the last two weeks.  He has no other medical problems and is compliant with his annual physical examinations.  On further questioning, he recalls recovering from a transient, non-pruritic rash a few months ago that he attributed to his vitamin E supplement.  He works as a corporate attorney serving a large number of customers overseas, and returned from a business trip to Thailand two months ago.
His medications include calcium, vitamin D, and occasional green tea tablets.  He stopped taking vitamin E shortly after the appearance of the rash.  He denies smoking and drinks socially.  He experienced an anaphylactic reaction to penicillin as a child.
His vital signs are within normal limits.  Examination shows no abnormalities.
Laboratory studies showed a normal complete blood count and metabolic panel.  His serum RPR titer is reactive at 1:50 and he has a reactive FTA-ABS.  HIV ELISA testing was negative.  Head CT is normal. 
Cerebral spinal fluid (CSF) analysis is as follows:

Which of the following is the next best step in management?

Quizplus · Accepted Answer

11ec193a_9849_97dc_853d_8db351ec987c_MD0002_00 This patient's presentation is consistent with early neurosyphilis, which can present as various syndromes during any stage of syphilis (summarized in the above table). Neurosyphilis begins with CSF invasion and can cause CSF laboratory abnormalities without clinical symptoms. Patients with neurological symptoms should undergo CSF examination. Cerebrospinal fluid with positive VDRL, lymphocytic pleocytosis, and elevated protein confirms the diagnosis. Since cerebrospinal fluid VDRL may be negative in up to 70% of patients, a positive test is helpful for establishing the diagnosis, but a negative test does not rule out neurosyphilis. Aqueous intravenous crystalline penicillin G for 10-14 days is the preferred treatment for neurosyphilis. Patients with a possible penicillin allergy should undergo skin testing and desensitization (in consultation with a specialist) if positive. Patients should also undergo serial CSF analysis 3-6 months after treatment and then every 6 months until the CSF shows a normal WBC count and negative VDRL. Patients failing to achieve this after 2 years require retreatment. (Choice B) Intravenous ceftriaxone is an alternative treatment for neurosyphilis in patients with mild penicillin allergy. Cephalosporins have cross reactivity in penicillin-allergic patients. Thus, administering ceftriaxone is permissible with mild penicillin allergy with careful monitoring; it is not recommended for severe penicillin-allergic patients. (Choice C) Doxycycline is an alternative therapy for primary or secondary syphilis in patients allergic to penicillin. However, it is not preferred for neurosyphilis unless the patient refuses penicillin desensitization or cannot take ceftriaxone or penicillin. (Choice D) Ibuprofen and other supportive therapy can be offered for alleviation of symptoms only, but it should not replace antimicrobial therapy. (Choice E) Repeat serum RPR with normalization can be used as a marker of neurosyphilis treatment success in immunocompetent patients or HIV patients taking anti-retrovirals. However, this patient should first be treated before measuring repeat serum RPR. Educational objective: Penicillin is the drug of choice to treat neurosyphilis, which can present with a variety of syndromes. Patients with a history of penicillin allergy should undergo desensitization in a monitored inpatient setting. __________ References: Treatment of neurosyphilis. (http://www.ncbi.nlm.nih.gov/pubmed/16569377)

A 42-Year-Old Man Comes to the Physician Because of a Dull