Winning Abstracts from the 2013 Medical Student Abstract Competition: Secondary Syphilis: Much More Than a Rash
Author: Catherine L. Meeker, Oregon Health & Science University School of Medicine, Class of 2014
Introduction: The characteristic feature of secondary syphilis is a rash, but its lesser-known symptoms create a presentation that can mimic mononucleosis, primary HIV, or other clinical entities. We report the case of an uncommon presentation of syphilis in a patient who presented with abdominal pain, B-symptoms, and a large abdominal mass concerning for a GI lymphoma.
Case Presentation: A previously healthy 20 year-old homosexual male presented to our medical center with one week of fevers, chills, night-sweats, and severe epigastric pain, three weeks after being evaluated at an outside urgent care center for a sore throat and penile irritation, both of which resolved in the interim period. Triage vital signs were T 37.9 °C, HR 128, RR 16, BP 119/49, Sp02 98% RA. Physical exam was notable for a thin, pale Caucasian male with severe epigastric tenderness to palpation without peritoneal signs. Non-tender bilateral 1cm inguinal lymph nodes were appreciated. Genital exam was otherwise unremarkable. An abnormal abdominal ultrasound in the ED prompted a CT, which revealed a periportal soft tissue mass measuring 2.5x7.0x8.5cm with multiple aortocaval and periaortic lymph nodes. Admission labs were remarkable for a WBC of 18.9K/mm3 with 85% neutrophils and no bandemia. LFTs and lipase were normal.
An excisional biopsy of an inguinal lymph node was pursued. Immunohisto-
chemical analysis of the specimen was negative for lymphoma and prototypical viruses. Similarly, serum PCR assays for EBV, CMV, HHV-6, and HIV were negative. With supportive care, his symptoms abated with concomitant normalization of his WBC. However, his alkaline phosphatase steadily rose, peaking at 319U/L. He was discharged on hospital day 7 with close outpatient follow up.
At his follow-up clinic visit, the patient was found to have continued elevation of alkaline phosphatase with new thrombocytosis to 739K/mm3. Further scouring of literature prompted sending an RPR, which came back reactive. State lab FTA testing confirmed the diagnosis of syphilis. He was treated appropriately with IM penicillin G with subsequent resolution of his symptomatology and laboratory derangements.
Discussion: In 2010, there were 45,834 new cases of syphilis, with the highest rates among men ages 20-29, with MSM accounting for 2/3 of all new cases of early-stage syphilis. Despite the fact that our patient was 20 years old and homosexual, syphilis was not on our initial differential because he lacked genital lesions, a rash, and/or neurological symptoms. We report this case to highlight the importance including syphilis on the differential for GI lymphoma, and to emphasize the less common signs and symptoms of secondary syphilis, a disease that is easily treatable if recognized early.
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