Syphilis: The Daily PANCE Blueprint

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Syphilis: The Daily PANCE Blueprint

A 24-year-old male presents to the STD clinic with a 3-day history of painless penile ulcer and bilateral inguinal lymphadenopathy. He reports unprotected sexual intercourse with a new partner 3 weeks ago. On examination, there is a non-tender, indurated ulcer with a clean base on the glans penis and bilateral, non-tender, firm inguinal lymphadenopathy. Darkfield microscopy of a sample from the ulcer reveals spirochetes with characteristic corkscrew motility. Rapid plasma reagin (RPR) test is positive at a titer of 1:32, and FTA-ABS is also positive. After confirming the patient has no known allergies, the provider administers benzathine penicillin G 2.4 million units intramuscularly. The patient returns 8 hours later with fever, headache, myalgias, and worsening of his skin lesions. Which of the following best explains the patient's current presentation?

A. Allergic reaction to penicillin
B. Jarisch-Herxheimer reaction
C. Neurosyphilis
D. Secondary syphilis
E. Serum sickness

Answer and topic summary

The answer is B. Jarisch-Herxheimer reaction

This patient is experiencing a Jarisch-Herxheimer reaction, which is an acute febrile reaction that commonly occurs within 24 hours (typically 2-8 hours) after initiating treatment for syphilis. The reaction is characterized by fever, headache, myalgias, and temporary worsening of syphilitic lesions. It results from the massive release of endotoxin-like substances, cytokines, and inflammatory mediators following the rapid killing of spirochetes by antibiotic therapy. The reaction is most common in patients with primary and secondary syphilis (occurring in up to 50% of cases) but can occur in any stage. The Jarisch-Herxheimer reaction is self-limited, typically resolving within 24-48 hours, and is not a reason to discontinue or change antibiotic therapy. Symptomatic treatment with antipyretics and NSAIDs is usually sufficient. The patient’s clinical presentation of a painless penile ulcer (chancre), lymphadenopathy, and positive serologic tests is consistent with primary syphilis, for which benzathine penicillin G is the recommended treatment.

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Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Spirochetal Disease ⇒ Syphilis

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