- 21-year-old male who has sex with men
- Past medical history notable for HIV infection; he is currently not taking antiretroviral medications and his CD4+ count is 43
- Review of systems is notable only for recent fevers in association with a new painless ulcer on the penis after a recent sexual encounter without barrier protection
- Tired-appearing, slightly cachectic male
- Fever is noted
- 1 cm well marginated ulcer with clean base and raised indurated border on the penile shaft with palpable inguinal lymphadenopathy
- Diagnosis: favor syphilitic chancre
- Ulcer fluid is evaluated by darkfield testing
- RPR, VDRL are tested
- Follow-up evaluation 3 days later
- The ulcer fluid reveals presence of spirochetes by darkfield microscopy and the RPR and VDRL are also both elevated.
- A complete physical, including neurologic evaluation, is performed (normal). Notably, no additional cutaneous signs of syphilis are found.
- A detailed sexual history is performed and his case (and contacts) are reported to the public health department.
- The patient is given an intramuscular dose of penicillin G benzathine 2.4 x 106 U.
- Follow-up evaluation in two weeks (ulcer healed) and he is also referred to primary care physician for ongoing management of his HIV disease. The patient is followed clinically and serologically three months later and every three months following for the first year, and then one year afterwards. Over this monitoring period, his serologic titers were reduced to undetectable levels and he exhibited no additional signs of syphilis infection.