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. Additional tests are performed and are normal. Which of the following is the best treatment option?

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. Additional tests are performed and are normal.  Which of the following is the best treatment option?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfc3_989f_8f63_5ff292f5af17_MD0005_00 Syphilis infections are characterized by periods of latency and periods of active disease. Treatment must be targeted to the current stage of illness, which is typically determined by: Symptoms Duration of infection (if known) Cerebrospinal fluid (CSF) evidence of neurosyphilis This patient with positive syphilis serology has no clear evidence of primary (eg, chancre), secondary (eg, diffuse rash, condylomata lata), or tertiary (eg, neurosyphilis, aortitis) syphilis, indicating latent infection. As the duration of his infection is unknown, he should be treated with intramuscular benzathine penicillin G weekly for 3 weeks. (Choice A) Patients with primary, secondary, or early latent syphilis (<1 year duration) should receive a single dose of intramuscular benzathine penicillin G. (Choice C) Patients with neurosyphilis or ocular syphilis require intravenous aqueous crystalline penicillin G for 10-14 days. Although this patient has blurry vision, his ocular and CSF evaluations are normal; therefore, he does not require treatment for ocular or neurosyphilis. (Choice D) Patients with tertiary syphilis (other than neurosyphilis) who have anaphylactic reactions to penicillin can be treated with 2 weeks of ceftriaxone. This patient has no evidence of tertiary syphilis and no history of penicillin allergy. (Choice E) Patients with anaphylactic penicillin allergies who have late latent syphilis or latent syphilis of unknown duration can receive alternate treatment with doxycycline for 28 days. This patient has no history of penicillin allergy; he should receive penicillin, not doxycycline, to reduce risk of treatment failure. Educational objective: Latent syphilis is defined as serologic evidence of infection with no clear evidence of primary, secondary, or tertiary disease. Patients with late latent syphilis (infection >1 year) or latent syphilis of unknown duration are treated with intramuscular benzathine penicillin G weekly for 3 weeks. References: Treatment of syphilis in HIV-infected subjects: a systematic review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/20924048) Response of HIV-infected patients with syphilis to therapy with penicillin or intravenous ceftriaxone. (http://www.ncbi.nlm.nih.gov/pubmed/21463980)

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