Alpha, Subgroup B - Interesting Case

ALPHA 1 SUBGROUP 1
The Imitation Game
Subgroup 1: De Lara, Dela Cruz, Falceso, Fernandez, Gines, Gomez

GENERAL DATA
Name: J.M.B
Age: 29
Sex: Male
Address: Tagkawayan, Quezon
Birthday: October 7, 1993
CHIEF COMPLAINT
Circular patches on the trunk and legs

HISTORY OF PRESENT ILLNESS
2 months PTC, Patient allegedly had chickenpox

which resolved spontaneously.
In interim, patient had his annual physical

examination at the company where he works
wherein the patient had his chest x-ray result with
an incidental finding of Pulmonary Tuberculosis
on the bilateral apical lung field.
during their APE as well, the patient, however

asymptomatic with STI symptoms was tested for
VDRL due to his history of multiple sexual partners.
RESULTS:
VDRL (02/21/2023): Reactive
1 month PTC, patient was still asymptomatic.

Patient started his treatment at San Pablo Health
Center for PTB. Patient had no noted symptoms
such as rashes, changes in vision, jaundice,
decrease in urination after initiation of treatment.
In the interim, patient was apparently well until..
1 week PTC, Patient noted onset of circular patches over his

chest, abdomen and legs with associated erythema and
pruritus.
Initially, patient thought that it was still secondary to chicken

pox which he had 2 months PTC. No medications taken.
3 days PTC, patient sought follow up consult at company clinic

and was requested to do repeat CXR and Syphilis work up
which revealed the following results:
RPR (04/11/2023)
Reactive
Syphilis ASV (04/11/2023)

200.00; COV: 1, 000; Reactive
CXR (04/11/2023)
PTB: Both upper lungs
Patient then sought consult at our institution for

further evaluation of circular skin patches as well
as interpretation of his laboratory results.
PAST MEDICAL HISTORY
● (-) Hypertension Current Medications:
● (-) Diabetes Mellitus ● (+) HRZE ( 1 month)
● (-) Bronchial Asthma
● (-) PTB Immunization History:
● (-) CVD ● COVID Vaccine: 2 primary doses, 1
● (-) CAD booster
● (-) Epilepsy
● (-) Cancer
● (-) Allergies
● (+) Chicken Pox (Feb 15, 2023)
FAMILY HISTORY
● (-) Hypertension
● (-) Diabetes Mellitus
● (-) Bronchial Asthma
● (-) PTB
● (-) CVD
● (-) CAD
● (-) Epilepsy
● (-) Cancer
● (-) Allergies
PERSONAL AND SOCIAL HISTORY
Occupation Food Preference
● Massage therapist ● Vegetables
● Fruits
Religion
● Catholic
Smoking History Patient lives with lived-in partner of 8

● 7 pack/years years.
Drinking History
● Occasional alcoholic beverage
drinker (3 bottles/occasion)
SEXUAL HISTORY
Last Sexual Contact: January 2023
No. of Sexual Partner: 4 sexual partners

● Female: Vaginal Sex
● 1 Male partner (32 y/o): Anal (Patient is the
giver), Oral (Patient is the receiver)
Protection: None
Symptoms: None
History of STI: None

REVIEW OF SYSTEMS
SKIN no pallor, no cyanosis, no rashes

CONSTITUTIONAL no fever, no weight gain/loss
HEENT no headache, no blurring of vision, no ringing of ears,
no hearing loss, no eye redness
RESPIRATORY no difficulty of breathing, no cough, no hemoptysis
CARDIOVASCULAR no chest pain, no orthopnea, no PND, no easy
fatigability, no edema
REVIEW OF SYSTEMS
GASTROINTESTINAL no abdominal pain, no jaundice, no nausea/vomiting,

no diarrhea, no constipation
GENITOURINARY no frequency, no intermittency, no hematuria, no
passage of sandy material, no dribbling, no hesitancy,
no painful urination
ENDOCRINE no polyuria, no polyphagia, no polydipsia
REVIEW OF SYSTEMS
NEUROLOGIC no weakness, no memory impairment, no

numbness/paresthesia, no dizziness
MUSCULOSKELETAL no muscle pain, no joint pain, no bone pain, no
tremors
PHYSICAL EXAMINATION
General Survey
● Awake, coherent, and not in cardiorespiratory distress
Vital Signs
Blood Pressure 110/70 mmHg
Heart Rate 70 bpm
Respiratory Rate 18 cpm
Temperature 36.5 oC
O2 Saturation 99%
Anthropometrics
Weight 56 kg
Height 170 cm
Body Mass Index 19.3 kg/m2, Normal (WHO Asia-Pacific BMI Classification)
SKIN/ Skin is dark colored, (+) hyperkeratotic scar, forearm,

INTEGUMENTARY dorsal, right; (+) skin-colored annular patches,
generalized
HEENT anicteric sclera, pink palpebral conjunctiva, and no
cervical lymphadenopathy
CHEST AND LUNGS symmetric chest expansion, clear breath sounds, and
no retractions
HEART adynamic precordium, normal rate and regular
rhythm, and no murmurs
ABDOMEN soft and nontender abdomen

GENITOURINARY Penis is normal looking, hair sparse, (-) lesions, (-)mass,
(-) discharge
EXTREMITIES grossly normal extremities, with full equal pulses and
CRT < 2 seconds, (+) skin-colored annular patches
CEREBRUM conscious, coherent and oriented

CEREBELLUM no nystagmus, no tremor
CN I N/A
CN II, III pupils equally reactive to light
CN III, IV, VI extraocular muscles intact
CN V equal facial sensation
CN VII equal facial movements
CN VIII Not done

CN IX, X uvula at midline
CN XI shoulder shrug intact
CN XII tongue is midline
MOTOR 5/5 on all upper and lower extremities
SENSORY 100% on all upper and lower extremities
LABORATORY RESULTS
MICROBIOLOGY TESTING
VDRL (02/21/2023)
Reactive
RPR (04/11/2023)
Reactive
Syphilis (04/11/2023)
ASV: 200.00; COV: 1, 000; Reactive
CHEST X-RAY (04/11/2023)

Pulmonary Tuberculosis: Both upper lungs
SALIENT FEATURES
PERTINENT POSITIVES PERTINENT NEGATIVES
History History
Past Medical History ● No history of Sexually Transmitted Infections

● No noted history of symptoms related to STIs
● (+) Pulmonary Tuberculosis (March 2023)- ● (-) Symptoms: Weight loss, Fever, Joint Pain,
on-going treatment Lymphadenopathy
● (+) Chickenpox (February 2023)
Physical Exam
Sexual History
● 4 lifetime sexual partners (Both Male and Females) ● Genitourinary PE:

○ Normal Looking Penis
Physical Exam ○ No mass
○ No lesions
● (+) Generalized skin colored annular patches all
over the trunk and extremities ○ No discharge
APPROACH TO DIAGNOSIS
Annular skin patches

Post-Varicella Infection
Scar
Hx: Chickenpox
(Feb 2023)
Usual presentation:
Hyperpigmented,
sunken/pitted scars
Post-Varicella Infection
Scar
Non-Sexual Etiologies Sexual Etiologies

Post-Varicella
Hx: Chickenpox
Infection
(Feb
Scar
2023)
Drug Pityriasis
Eruption Rosea
DRUG ERUPTION
RULE IN RULE OUT
History History
● (+) Pulmonary Tuberculosis (March 2023)- ● Multiple lifetime sexual partners

on-going treatment
Diagnostics
● Onset of skin lesions - 1 week PTC
● Positive in both qualitative Syphilis tests
Physical Exam
(RPR, VDRL)
● Annular patches on the trunk and ● Positive in quantitative Syphilis test
extremities
References:
Sharma, R. K., Verma, G. K., Tegta, G. R., Sood, S., Rattan, R., & Gupta, M. (2020). Spectrum of Cutaneous Adverse Drug Reactions to Anti-tubercular Drugs and Safe
Therapy after Re-challenge - A Retrospective Study. Indian dermatology online journal, 11(2), 177–181. https://doi.org/10.4103/idoj.IDOJ_133_19
DRUG ERUPTION
Case Picture of Lesion Representative Picture of Lesion
Reference: Wu, W.-H., & Chu, C.-Y. (2021). Annular drug eruptions. Clinics in Dermatology,
40(5), 450–465. https://doi.org/10.1016/j.clindermatol.2021.12.008
DRUG ERUPTION
RULE IN RULE OUT
History History
● (+) Pulmonary Tuberculosis (March 2023)- ● Multiple lifetime sexual partners

on-going treatmen
Diagnostics
Physical Exam
RULED OUT
● Annular patches on the trunk and (RPR, VDRL)
extremities ● Positive in quantitative Syphilis test
PITYRIASIS ROSEA
RULE IN RULE OUT
History History
● (-) Nonspecific symptoms leading to the lesions

● Age: 29
● Multiple lifetime sexual partners
Physical Exam
Physical Exam
● Annular patches on the trunk and
● Non-raised, non-erythematous, no scaling
extremities
Diagnostics
● Positive in both qualitative Syphilis tests (RPR,

VDRL)
● Positive in quantitative Syphilis test
References:
STULBERG, D. L., & WOLFREY, J. (2004). Pityriasis Rosea. American Family Physician, 69(1), 87–91. https://www.aafp.org/pubs/afp/issues/2004/0101/p87.html
DermNet. (2022). Dermnetnz.org. https://dermnetnz.org/topics/pityriasis-rosea
PITYRIASIS ROSEA
Reference: STULBERG, D. L., & WOLFREY, J. (2004). Pityriasis Rosea. American Family
Physician, 69(1), 87–91. https://www.aafp.org/pubs/afp/issues/2004/0101/p87.html
PITYRIASIS ROSEA
RULE IN RULE OUT
History History
● (-) Nonspecific symptoms leading to the lesions

● Age: 29
Physical Exam
Physical Exam
● Annular patches on the trunk and RULED OUT
● Non-raised, non-erythematous, no scaling
extremities
Diagnostics

VDRL)
References:
STULBERG, D. L., & WOLFREY, J. (2004). Pityriasis Rosea. American Family Physician, 69(1), 87–91. https://www.aafp.org/pubs/afp/issues/2004/0101/p87.html
DermNet. (2022). Dermnetnz.org. https://dermnetnz.org/topics/pityriasis-rosea
Post-Varicella
Hx: Chickenpox
Infection
(Feb
Scar
2023)
Drug Nummular Syphilis

Eruption Eczema (Secondary )
SYPHILIS (Secondary)
RULE IN RULE OUT
History

Physical Exam
Physical Exam
● (-) Maculo papular rashes on hands and feet
● (-) Lesions on penile area
● Annular patches on the trunk and extremities
Diagnostics

VDRL)
References:
It, A. (2022). Skin rash and lesions – general - STI Guidelines Australia. https://sti.guidelines.org.au/syndromes/skin-rash-and-lesions-general/
Morris, S. R. (2023a, January). Syphilis. MSD Manuals. Retrieved April 30, 2023, from https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Morris, S. R. (2023b, April 18). Syphilis. MSD Manual Professional Edition. https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Wolff, K., Goldsmith, L., Katz, S., Gilchrest, B., Paller, A., & Leffell, D. (2008). Fitzpatrick’s Dermatology in General Medicine (7th ed., Vols. 1–2) [PDF]. Mc-Graw Hill Medical. https://doi.org/10.1036/0071466908
Reference: Morris, S. R. (2023, April 18). Syphilis. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-
stis/syphilis#v1024232
RULE IN RULE OUT
History Physical Exam
● (-) Maculo papular rashes on hands and feet
Physical Exam
● Annular patches on the trunk and
extremities RULE IN
Diagnostics
(RPR, VDRL)
References:
It, A. (2022). Skin rash and lesions – general - STI Guidelines Australia. https://sti.guidelines.org.au/syndromes/skin-rash-and-lesions-general/
Morris, S. R. (2023a, January). Syphilis. MSD Manuals. Retrieved April 30, 2023, from https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Morris, S. R. (2023b, April 18). Syphilis. MSD Manual Professional Edition. https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Wolff, K., Goldsmith, L., Katz, S., Gilchrest, B., Paller, A., & Leffell, D. (2008). Fitzpatrick’s Dermatology in General Medicine (7th ed., Vols. 1–2) [PDF]. Mc-Graw Hill Medical. https://doi.org/10.1036/0071466908
Working Impression
T/C Sexually Transmitted Infection;

Pulmonary Tuberculosis, on going treatment
(San Pablo LHC, 2023)
Why STI not Secondary Syphilis?
● In a study by Mahmud et al in 2023, over We have to further evaluate for HIV as needed.
the last 10 years, the Philippines has a
pooled prevalence of 7.38% for
co-infection of Syphilis with HIV.
● Tuberculosis is greatly associated with
HIV, and is now considered as a
“AIDS-defining illness”
● Dr. Salvana in 2016 conducted a study in a
tertiary hospital in the PH which
investigates on the prevalence of HIV cases
among patients with TB, STDs and Cervical
CA.
○ Prevalence of TB (2.5%) and STDs (1.98%) >
1% international prevalence→
recommendation for universal screening of
HIV.
What made this case
interesting?
It is not often what we
think they seem.
The patient did not present any
systemic signs and symptoms aside
from the lesions. It was through
probing of the patient’s sexual
history did we have a hunch as to the
etiology of the disease.
As doctors, therefore, we ought to be

more proactive in our history and
physical examination.
Stages of Syphilis
MANAGEMENT
Plan
Diet: Well balanced diet with adequate oral fluid intake (2-3L/day).
Diagnostics:
1) STI Panel Work-Up
2) Qualitative VDRL
Therapeutics:
1) Noted on-going PTB treatment
Health Education:
1) Advised sexual abstinence
2) Advised diet and lifestyle modifications
3) Follow up on April 17, 2023 (Monday)
4) Plan to give Benzathine Penicillin G 2.4 millions dose once with results of VDRL/RPR.
Diet Recommendations
● Eat plenty of fresh fruit and vegetables
● Avoid high fat, salty foods., and processed foods
○ May make your system too sluggish to fight off disease.
Diagnostic Methods in Different Stages of
Syphilis
Diagnostic Considerations
Diagnostic Considerations
Syphilis and HIV
● Patients with HIV infected with syphilis have an increased risk of neurological
complications
○ CSF abnormalities are associated with a CD4+ T-cell count of ≤350 cells/mL or an RPR titer of
≥1:32
● All persons with HIV infection and primary and secondary syphilis should have a
thorough neurologic, ocular, and otic examination
● Recommended Regimen for Primary and Secondary Syphilis Among Persons
with HIV Infection : Benzathine penicillin G 2.4 million units IM in a single dose
● Careful follow up after therapy
○ Evaluated clinically and serologically for possible treatment failure at 3, 6, 9, 12, and 24 months
after therapy
Centers for Disease Control and Prevention. (2021). Sexually Transmitted Infections Treatment Guidelines. Atlanta:
U.S. Department of Health and Human Services.
Syphilis and HIV
● HIV infection can be diagnosed by HIV 1/2 Ag/Ab combination immunoassays
Syphilis and Pulmonary Tuberculosis
● Statistical statements and clinical observation indicate that syphilis hastens the
development of tuberculosis
● Latent syphilis can produce the same initial symptoms as PTB
Therapeutics
A single injection of long-acting Benzathine

penicillin G can cure the early stages of syphilis
(primary, secondary, or early latent syphilis)
Centers for Disease Control and Prevention. (2022, January 3). Syphilis Treatment and Care. Retrieved from CDC:
https://www.cdc.gov/std/syphilis/treatment.htm#:~:text=A%20single%20injection%20of%20long,latent%20syp
hilis%20of%20unknown%20duration.
Penicillin Allergy
Validating Penicillin Allergy
1. Thorough medical history
2. Performing a skin test evaluation by using the penicillin major and minor
determinants
3. If (-) skin test, observed oral challenge with 250 mg amoxicillin before
proceeding directly to treatment with the indicated ß-lactam therapy
- If (+) skin test, other effective antimicrobials should be used
https://www.cdc.gov/std/syphilis/treatment.htm#:~:text=A%20single%20injection%20of%20long,latent%20syp
hilis%20of%20unknown%20duration.
Skin test reagents for identifying persons at risk for adverse reactions to
penicillin
Penicillin Allergy
Alternatives to Penicillin
1. Doxycycline (100 mg orally 2 times/day for 14 days)
2. Tetracycline (500 mg orally 4 times/day for 14 days)
a. Has more gastrointestinal side effects and requires more frequent dosing
3. Ceftriaxone (1 g daily either IM or IV for 10 days)
a. Optimal dose and duration of ceftriaxone therapy have not been defined
4. Azithromycin as a single 2-g oral dose
a. T. pallidum chromosomal mutations associated with azithromycin and other macrolide
resistance
b. Not recommended
Jarisch-Herxheimer Reaction
● Acute febrile reaction occurring within the first 24h of starting syphilis
treatment
○ Headache
○ Myalgia
○ Fever
● Advise the patient to use antipyretics
Management of Sexual Partners
Evaluated clinically and serologically and treated according to the following
recommendations:
● Persons who have had sexual contact with a person who receives a diagnosis of
primary, secondary, or early latent syphilis <90 days before the diagnosis should
be treated presumptively for early syphilis, even if serologic test results are
negative
● Persons who have had sexual contact with a person who receives a diagnosis of
primary, secondary, or early latent syphilis >90 days before the diagnosis should
be treated presumptively for early syphilis if serologic test results are not
immediately available and the opportunity for follow-up is uncertain
○ If serologic tests are negative, no treatment is needed.
○ If serologic tests are positive, treatment should be based on clinical and serologic evaluation and
syphilis stage
Management of Sexual Partners
● In certain areas or among populations with high syphilis infection rates, health
departments recommend notification and presumptive treatment of sex partners of
persons with syphilis of unknown duration who have high nontreponemal serologic
test titers (i.e., >1:32) because high titers might be indicative of early syphilis. These
partners should be managed as if the index patient had early syphilis.
● Long-term sex partners of persons who have late latent syphilis should be evaluated
clinically and serologically for syphilis and treated on the basis of the evaluation
findings.
● The following sex partners of persons with syphilis are considered at risk for infection
and should be confidentially notified of the exposure and need for evaluation: partners
who have had sexual contact within 3 months plus the duration of symptoms for
persons who receive a diagnosis of primary syphilis, within 6 months plus duration of
symptoms for those with secondary syphilis, and within 1 year for persons with early
latent syphilis.
Follow-Up
● Clinical and serological evaluation at 6 and 12 months after treatment
● Reinfected or Treatment failure
○ Persistence or recurrence of symptoms
○ At least a fourfold increase in nontreponemal test titer persisting for >2 weeks
● Treatment failure or with neurological findings
○ CSF examination
○ Evaluation for HIV
● Reinfection: patients with no neurlogical findings but are sexually active
○ Repeat treatment: weekly injections of benzathine penicillin G 2.4 million units intramuscularly
(IM) for 3 weeks is recommended
○ Evaluation for HIV
REFERENCES
Centers for Disease Control and Prevention. (2021). Sexually Transmitted Infections Treatment Guidelines. Atlanta: U.S. Department of
Health and Human Services.
https://www.cdc.gov/std/syphilis/treatment.htm#:~:text=A%20single%20injection%20of%20long,latent%20syphilis%20of%20unk
nown%20duration.
It, A. (2022). Skin rash and lesions – general - STI Guidelines Australia.
https://sti.guidelines.org.au/syndromes/skin-rash-and-lesions-general/
Luo, Y., Xie, Y., & Xiao, Y. (2021). Laboratory Diagnostic Tools for Syphilis: Current Status and Future Prospects. Frontiers in Cellular
and Infection Microbiology, 1-12.
Morris, S. R. (2023a, January). Syphilis. MSD Manuals. Retrieved April 30, 2023, from
https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Morris, S. R. (2023b, April 18). Syphilis. MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/infectious-diseases/sexually-transmitted-infections-stis/syphilis#v1024232
Wolff, K., Goldsmith, L., Katz, S., Gilchrest, B., Paller, A., & Leffell, D. (2008). Fitzpatrick’s Dermatology in General Medicine (7th ed.,
Vols. 1–2) [PDF]. Mc-Graw Hill Medical. https://doi.org/10.1036/0071466908
Wu, W.-H., & Chu, C.-Y. (2021). Annular drug eruptions. Clinics in Dermatology, 40(5), 450–465.
https://doi.org/10.1016/j.clindermatol.2021.12.008

Alpha, Subgroup B - Interesting Case

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ALPHA 1 SUBGROUP 1

The Imitation Game

Subgroup 1: De Lara, Dela Cruz, Falceso, Fernandez, Gines, Gomez

Circular patches on the trunk and legs

2 months PTC, Patient allegedly had chickenpox

In interim, patient had his annual physical

during their APE as well, the patient, however

1 month PTC, patient was still asymptomatic.

In the interim, patient was apparently well until..

1 week PTC, Patient noted onset of circular patches over his

Initially, patient thought that it was still secondary to chicken

3 days PTC, patient sought follow up consult at company clinic

Syphilis ASV (04/11/2023)

Patient then sought consult at our institution for

Smoking History Patient lives with lived-in partner of 8

Last Sexual Contact: January 2023

No. of Sexual Partner: 4 sexual partners

History of STI: None

SKIN no pallor, no cyanosis, no rashes

GASTROINTESTINAL no abdominal pain, no jaundice, no nausea/vomiting,

NEUROLOGIC no weakness, no memory impairment, no

SKIN/ Skin is dark colored, (+) hyperkeratotic scar, forearm,

ABDOMEN soft and nontender abdomen

CEREBRUM conscious, coherent and oriented

CN VIII Not done

CHEST X-RAY (04/11/2023)

Past Medical History ● No history of Sexually Transmitted Infections

● 4 lifetime sexual partners (Both Male and Females) ● Genitourinary PE:

Annular skin patches

Non-Sexual Etiologies Sexual Etiologies

Non-Sexual Etiologies Sexual Etiologies

● (+) Pulmonary Tuberculosis (March 2023)- ● Multiple lifetime sexual partners

● (+) Pulmonary Tuberculosis (March 2023)- ● Multiple lifetime sexual partners

● (-) Nonspeciﬁc symptoms leading to the lesions

● Positive in both qualitative Syphilis tests (RPR,

● (-) Nonspeciﬁc symptoms leading to the lesions

● Positive in both qualitative Syphilis tests (RPR,

Non-Sexual Etiologies Sexual Etiologies

Drug Nummular Syphilis

● Multiple lifetime sexual partners

● Positive in both qualitative Syphilis tests (RPR,

T/C Sexually Transmitted Infection;

As doctors, therefore, we ought to be

1) STI Panel Work-Up

1) Noted on-going PTB treatment

1) Advised sexual abstinence

2) Advised diet and lifestyle modiﬁcations

3) Follow up on April 17, 2023 (Monday)

A single injection of long-acting Benzathine

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