A 27-year-old previously healthy man comes to the office for sexually transmitted infection screening. A month ago, the patient had a sexual encounter with a woman he met at a bar. He used a condom but discovered that it ruptured during intercourse. The woman denied having sexually transmitted infections. The patient has no dysuria, urethral discharge, or genital lesions but wants to be tested for infections. He is a graduate student and occasionally drinks alcohol but does not use tobacco or injection drugs. He has had several female sexual partners and uses condoms consistently. Temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 78/min. The patient appears anxious. Oropharyngeal mucosa is normal without any lesions. No enlarged lymph nodes are present. Cardiopulmonary examination is normal. The abdomen is soft and nontender with no hepatosplenomegaly. External genitalia appear normal. Bilateral testes are soft, nontender, and of normal size. Which of the following is the most appropriate diagnostic test for this patient?

Question

A 27-year-old previously healthy man comes to the office for sexually transmitted infection screening.  A month ago, the patient had a sexual encounter with a woman he met at a bar.  He used a condom but discovered that it ruptured during intercourse.  The woman denied having sexually transmitted infections.  The patient has no dysuria, urethral discharge, or genital lesions but wants to be tested for infections.  He is a graduate student and occasionally drinks alcohol but does not use tobacco or injection drugs.  He has had several female sexual partners and uses condoms consistently.  Temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 78/min.  The patient appears anxious.  Oropharyngeal mucosa is normal without any lesions.  No enlarged lymph nodes are present.  Cardiopulmonary examination is normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  External genitalia appear normal.  Bilateral testes are soft, nontender, and of normal size.  Which of the following is the most appropriate diagnostic test for this patient?

Quizplus · Accepted Answer

Explanation: Recommendations for sexually transmitted infection (STI) screening are fairly nuanced and depend on many factors, including gender, sexual orientation, age, high-risk behavior, and symptoms. However, most STI screening guidelines recommend that patients age 13-65 receive HIV screening with a fourth-generation HIV test (p24 antigen and HIV antibodies), regardless of the presence or absence of risk factors. Early identification of HIV allows for the initiation of antiretroviral therapy, administration of appropriate vaccinations, and early suppression of viral load (which reduces transmission risk). Asymptomatic men who have sex with women and do not engage in high-risk behavior (eg, encounters with sex workers) generally do not require additional STI screening. If a sexual partner has a known or previous STI, then targeted testing is often performed. (Choice A) In the United States, hepatitis C virus is primarily transmitted by parenteral blood exposure during intravenous drug use; sexual transmission is uncommon. As such, HCV is not a routine part of STI screening. Testing for HCV is recommended in those with a risk factor (eg, history of injection drug use, blood transfusion before 1992, unregulated tattoo), with elevated alanine aminotransferase, or in high-prevalence groups (eg, HIV infection, hemodialysis, born 1945-1965, incarcerated). (Choice B) Routine screening for herpes simplex virus is generally not recommended for asymptomatic individuals. (Choice D) According to the United States Preventive Services Task Force, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention, there is not enough evidence to support routine chlamydia screening in asymptomatic men who have sex with women. However, high-risk (eg, men who have sex with men) or symptomatic men should receive testing. In general, compared to women, men are more likely to be symptomatic and less likely to have long-term sequelae from chlamydial infections. (Choice E) Trichomoniasis screening is not generally recommended for men. Educational objective: Most patients age 13-65 benefit from sexually transmitted infection (STI) screening with a fourth-generation HIV test, regardless of the presence or absence of risk factors. Additional STI screening depends on many factors, including gender, sexual orientation, age, high-risk behavior (eg, encounters with sex workers), and symptoms. References: Screening for HIV in health care settings: a guidance statement from the American College of Physicians and HIV Medicine Association. (http://www.ncbi.nlm.nih.gov/pubmed/19047022) Prevention of HIV-1 infection with early antiretroviral therapy. (http://www.ncbi.nlm.nih.gov/pubmed/21767103)

A 27-Year-Old Previously Healthy Man Comes to the Office for Sexually