Challenging STD Cases

Chris Davis, PA-C University of Utah Clinic 1A Case #1

• 28 year old HIV + MSM presents for first HIV visit with lesion on glans of penis • CD4 count of 3 and viral load of 610,000 • Multiple sexual partners over the past month. Versatile. • Also has multiple anal warts • Per patient negative RPR 6 months ago

Question #1: What is the most likely diagnosis given this history and clinical presentation?

A. Syphilis B. Kaposi’s Sarcoma C. Herpes D. Derm Condition Genital Lesion Initial Assessment: Diagnosis and Treatment

• Presumed herpes infection. Treated with Valcyclovir 1 gram bid • Offered cryotherapy for anal warts but patient refused. Referred to colorectal surgeon.

1. Why did we choose this treatment regimen for his Genital HSV? 2. Is this primary or recurrent infection? 3 Weeks Later

• RPR negative • Valtrex not helpful. Lesions have increased, painful, purulent discharge. Complains of fever, chills x 1 week. 100.2 in clinic • Negative chlamydia, gonorrhea • Another RPR drawn also negative

Question #2: What would you do next?

A. Biopsy the lesion B. Treat with a broadspectrum antibiotic for bacterial and fungal infection C. Refer to Dermatology for consult D. Treat presumptively for syphilis Dermatology Consult

• Diagnosed with molluscum contagiosum and impetigo in genital region with possible yeast infection • Swabs sent for bacterial infection, yeast, and HSV • Urine sent for GC/CT • Treated with Keflex 500 mg bid, Nystantin and Bactroban ointment and encouraged to do vinegar soaks 1 Month Later

• Genital lesions improving with antibiotic and ointments • Continues to have low grade fever and chills. Still thought to be viral URI

1 Week Later

• Presents with tachycardia, injected sclera, maculopapular rash on torso and back. • Thought to be reaction to Keflex. D/C’d and started on prednisone taper. 1 Day Later Syphilis

• 3rd RPR now at 1:32 • Treated with IV Penicillin. Rash resolved, penile lesions did scar but improved. • Treated as a late latent in outpatient clinic and given 2.4 million units of Bicillin weekly x 3 weeks.

Why did we stage this patient Late Latent Syphilis? Syphilis

• Due to false negative results, especially with HIV infection, treponemal tests should be used to confirm. • False negative RPR may occur as a result of the prozone phenomenon. Seen when antibody concentrations are very high (usually in secondary syphilis) and the specimen is not diluted enough. Also called the hook effect. • Video Case #2

• 26 year old HIV + MSM presents with 3 days of penile discharge and sore throat • Admits to unprotected oral and insertive anal intercourse last week Question #1: How would you manage this patient?

A. Treat presumptively for GC/CT. No labs need to be collected. B. Collect urine and pharyngeal swab for GC/CT and treat presumptively for GC/CT C. Collect urine and pharyngeal swab for GC/CT and await results Initial Clinic Management

• Urine and pharyngeal swab sent to lab for GC/CT • Treated empirically for GC/CT with Ceftriaxone 250 mg. IM plus 1 g. PO Azithromycin

3 Weeks Later

• Pharyngeal swab positive for chlamydia • Urine GC/CT negative • Discharge resolved, no sore throat

1 Month Later

• Returns with another sore throat and penile discharge • Admits to different unsafe sexual partner.

Question #2: How do we manage this patient now?

A. Repeat labs and GC/CT treatment as per initial visit B. Repeat labs and wait for test results before treatment 1 Month Later: Patient Management

• Treated empirically for GC/CT • Given a ‘come to Jesus’ talk. • Given huge bag of condoms • Urine and pharyngeal swab sent for GC/CT testing

1 Month Later

• Sore throat resolved continues with discharge • Swab, urine GC/CT all negative. • Urine GC/CT sent again along with chlamydial culture • All come back negative

What do we do now? Final Patient Management

• Dr. John Krisel consulted recommends checking for Mycoplasma genitalium • Treated empirically with Flagyl 2000 mg x once and moxifloxicin 400 mg daily x 10 days. • Discharge improves almost immediately • Swab for Mycoplasma genitalium returns positive • Patient later discovered to have chronic tonsillitis, has tonsillectomy and greatly improves Mycoplasma Genitalium

• First reported in 1981 and eventually identified as a new species of Mycoplasma in 1983. • In contrast syphilis first described in 1494 Mycoplasma Genitalium

• Highly associated with HIV infection • Symptoms: – None – Dysuria – Mucopurlent discharge