A 24-year-old man comes to the urgent care clinic with fevers and chills that developed when he awoke this morning. He also has diffuse body aches, most pronounced in his shoulders and knees. Two days ago, the patient was seen by his primary care provider due to a skin rash and was diagnosed with secondary syphilis. HIV testing was negative, and urine testing for gonorrhea and chlamydia was negative. He received a dose of intramuscular benzathine penicillin G yesterday afternoon.
Currently, the patient's temperature is 39 C (102.2 F), blood pressure is 114/64 mm Hg, pulse is 72/min, and respirations are 18/min. He is uncomfortable but not acutely ill-appearing. Oropharynx examination does not show any abnormalities. His lungs are clear bilaterally. The patient's abdomen is soft and nontender throughout. He has scattered macular, erythematous regions on his abdomen, back, shoulders, and lower extremities, which he reports have progressed since his initial presentation 2 days ago.
What is the most appropriate initial treatment for this patient?

Question

A 24-year-old man comes to the urgent care clinic with fevers and chills that developed when he awoke this morning.  He also has diffuse body aches, most pronounced in his shoulders and knees.  Two days ago, the patient was seen by his primary care provider due to a skin rash and was diagnosed with secondary syphilis.  HIV testing was negative, and urine testing for gonorrhea and chlamydia was negative.  He received a dose of intramuscular benzathine penicillin G yesterday afternoon.
Currently, the patient's temperature is 39 C (102.2 F), blood pressure is 114/64 mm Hg, pulse is 72/min, and respirations are 18/min.  He is uncomfortable but not acutely ill-appearing.  Oropharynx examination does not show any abnormalities.  His lungs are clear bilaterally.  The patient's abdomen is soft and nontender throughout.  He has scattered macular, erythematous regions on his abdomen, back, shoulders, and lower extremities, which he reports have progressed since his initial presentation 2 days ago.
What is the most appropriate initial treatment for this patient?

Quizplus · Accepted Answer

11ec193a_9869_7c26_853d_f3f234bcb4a0_MD0002_00 This patient has acute onset of fever, myalgias, and rash progression within 24 hours of secondary syphilis treatment with penicillin G. This presentation is most consistent with a Jarisch-Herxheimer reaction. This acute febrile illness is attributed to the release of Treponema pallidum components associated with organism death (eg, lipopolysaccharide, which leads to an abrupt release of inflammatory cytokines). The reaction typically begins within hours of antispirochete therapy administration and is self-limiting, usually resolving within 48 hours. Management consists of supportive care, including intravenous therapy and acetaminophen (which may reduce symptom duration). (Choice B) Corticosteroids are not routinely used in the management of Jarisch-Herxheimer reactions. Topical corticosteroids are used for some inflammatory skin conditions (eg, eczema). (Choice C) Doxycycline has activity against T pallidum and is used in cases of severe penicillin allergy. (Choice D) Valacyclovir is used in the management of herpes simplex virus infections, typically associated with vesicular lesions. (Choice E) Vancomycin has activity against gram-positive organisms. There is insufficient evidence to suggest that this patient's presentation is consistent with an acute bacterial infection (eg, no hypotension, not acutely ill-appearing). Educational objective: Jarisch-Herxheimer reaction should be considered in patients with an acute febrile illness following treatment for syphilis. Treatment is supportive and may include nonsteroidal anti-inflammatory drugs or acetaminophen. __________ References: The Jarisch-Herxheimer reaction: revisited. (http://www.ncbi.nlm.nih.gov/pubmed/23632012) Syphilis: a reemerging infection. (http://www.ncbi.nlm.nih.gov/pubmed/22963062)

A 24-Year-Old Man Comes to the Urgent Care Clinic with Fevers