A 26-year-old man comes to the office after learning that one of his sexual partners tested positive for HIV. The patient has had intermittent headaches, malaise, nausea, and blurry vision over the last several weeks. He has had no fever, sore throat, skin rash, genital lesions, or weight loss. The patient has no prior history of sexually transmitted infections or chronic medical problems. He smokes a pack of cigarettes daily, consumes alcohol occasionally, and does not use illicit drugs. The patient has had multiple sexual partners over the last several years and does not use condoms consistently. Temperature is 37.1 C (98.8 F), blood pressure is 122/74 mm Hg, and pulse is 72/min. There is no scleral icterus, oropharyngeal lesions, or skin rash. Mild, generalized lymphadenopathy is present. Cardiopulmonary and abdominal examinations are normal. Cranial nerves, deep tendon reflexes, and sensation are normal. No nuchal rigidity is present. Ophthalmologic examination reveals no abnormalities. Screening HIV immunoassay is positive. Other laboratory studies are as follows: A subsequent fluorescent treponemal antibody absorption test is positive. Contrast-enhanced CT scan of the head reveals no space-occupying lesions. Which of the following is the most appropriate next step in management of this patient's treponemal infection?

Question

A 26-year-old man comes to the office after learning that one of his sexual partners tested positive for HIV.  The patient has had intermittent headaches, malaise, nausea, and blurry vision over the last several weeks.  He has had no fever, sore throat, skin rash, genital lesions, or weight loss.  The patient has no prior history of sexually transmitted infections or chronic medical problems.  He smokes a pack of cigarettes daily, consumes alcohol occasionally, and does not use illicit drugs.  The patient has had multiple sexual partners over the last several years and does not use condoms consistently.  Temperature is 37.1 C (98.8 F), blood pressure is 122/74 mm Hg, and pulse is 72/min.  There is no scleral icterus, oropharyngeal lesions, or skin rash.  Mild, generalized lymphadenopathy is present.  Cardiopulmonary and abdominal examinations are normal.  Cranial nerves, deep tendon reflexes, and sensation are normal.  No nuchal rigidity is present.  Ophthalmologic examination reveals no abnormalities.  Screening HIV immunoassay is positive.  Other laboratory studies are as follows:  A subsequent fluorescent treponemal antibody absorption test is positive.  Contrast-enhanced CT scan of the head reveals no space-occupying lesions.  Which of the following is the most appropriate next step in management of this patient's treponemal infection?

Quizplus · Accepted Answer

Explanation: This patient with HIV has positive 2-step serology for syphilis, a sexually transmitted infection caused by the spirochete Treponema pallidum. Hematogenous dissemination of the spirochete occurs early in the disease course and frequently leads to seeding of the cerebrospinal fluid (CSF). Although this nervous system infection is usually asymptomatic at first and may clear spontaneously, any patient with syphilis who has neurologic symptoms (eg, headache, blurred vision) requires a lumbar puncture to evaluate for neurosyphilis. Patients with HIV are at greatest risk for developing neurosyphilis, particularly when CD4 counts are <350/mm³ and rapid plasma reagin titers are >1:128. Diagnosis is typically confirmed when CSF analysis reveals an elevated leukocyte count (>5/mm³) and positive VDRL or fluorescent treponemal antibody absorption (FTA-ABS) testing. (Choice A) Patients who do not have neurologic symptoms do not require additional testing and can proceed with treatment based on the stage of illness. This patient has neurologic symptoms and requires lumbar puncture prior to treatment (as the treatment for neurosyphilis is different from that for other stages of illness). (Choices B, C, and E) False positive nontreponemal testing (eg, rapid plasma reagin) can occur in patients with HIV but is usually low titer (<1:16) and associated with negative treponemal testing (eg, FTA-ABS). This patient with high titer nontreponemal testing and a positive treponemal test has syphilis. He does not require additional treponemal testing with T pallidum enzyme immunoassay or repeat serology. Lumbar puncture and appropriate treatment are now required and should not be delayed due to risk of progression and spread to others. Educational objective: Patients with syphilis who have neurologic signs or symptoms require a lumbar puncture to evaluate for neurosyphilis prior to consideration of treatment. References: Occurrence, risk factors, diagnosis and treatment of syphilis in the prospective observational Swiss HIV Cohort Study. (http://www.ncbi.nlm.nih.gov/pubmed/20616699) Neurosyphilis in the age of AIDS: clinical and laboratory features. (http://www.ncbi.nlm.nih.gov/pubmed/19768370)

A 26-Year-Old Man Comes to the Office After Learning That