The Case of the College Romeo

James, a twenty year old male college student, visits the student health clinic because of a rash that has developed over the past few days and is becoming more widespread. He said that he did not come in sooner because the rash does not itch and he thought it would go away like a similar rash he had about a month ago. The rash actually appears to be clusters of smaller rashes dispersed over his entire body, including the palms of his hands and the soles of his feet. The individual rash clusters are also somewhat similar, but not identical. In addition to the rash, James notes that he has been feeling tired lately and has lost his appetite. He also complains of a stiff neck and joints as well as watery eyes and a runny nose.

In obtaining a patient history the nurse practitioner notes that James is sexually active and claims to have had intercourse with approximately 40 different women over the past nine months. He says that he meets most of these women at either the nightclubs around campus or at various parties on campus. He states that he rarely sees each woman more than twice and does not routinely use condoms or any form of birth control since it "decreases the pleasure".

Physical examination revealed enlargement of the lymph nodes, splenomegaly, and hepatomegaly. In part, due to the anorexia, James has lost weight. In addition, the hair in his eyebrows and beard is thinning and he is beginning to suffer from a patchy alopecia. His body temperature is slightly elevated and his pulse, blood pressure and respiratory rate are all within normal ranges. The rash is as James described and does appear over his entire body. The rash is characterized by the nurse practitioner as being primarily macular and maculopapular with a symmetrical pattern. The individual spots in the lesions are pinkish red in color and become confluent with each other. In addition to the rash on his skin, the nurse practitioner notices that James has developed patches on the mucous membranes in his oral cavity. These patches are circular and grayish-white in color with a red areola.

The nurse practitioner tells James that she suspects he has contracted syphilis, a sexually transmitted disease. She asks James if at some time in the past few months if he noticed a sore, known as a chancre, on his penis. James said he did notice such a sore, but it was small and healed within two weeks. In order to confirm her diagnosis she tells James that she needs to run some tests. These include a blood test and testing samples from the lesions on his skin. The results of the blood test indicate James is suffering from anemia and jaundice. In addition, the serological tests specific for syphilis indicate the antibodies against Treponema pallidum, the syphilis pathogen, are present in his blood. The evaluation of the samples from the skin lesions confirms the present of the same organism. Since James is exhibiting neurological symptoms (headache, neck stiffness) she recommends a spinal tap to rule out neurosyphilis. The results of the spinal tap are negative for Treponema pallidum indicating an absence of neurosyphilis.

The nurse practitioner tells James that he has secondary syphilis. He will need to provide a list of names and telephone numbers of all women he has had sexual contact with over the last year. This is necessary in order to determine who may have infected James and also to inform the other women that they have been exposed to syphilis. James is to refrain from intercourse until his treatments end and he must have repeated tests to confirm the effectiveness of the treatment at 1, 3, 6, and 12 months post treatment or until a negative serological test is obtained. She also encourages James to consider undergoing a test for the human immunodeficiency virus (HIV) as he is at high risk for HIV infection. Finally, before starting the treatments, she encourages James to decrease his risk of contracting sexually transmitted diseases by using a condom and a spermicide and decreasing his number of sexual partners.

Since James has no drug allergies, the nurse practitioner then gives James 2.4 million units of penicillin G (two intramuscular injections of 1.2 million units, one injection into each of his buttocks) and tells him to return once each week for the next two weeks for additional penicillin treatment. She reminds James that he is not to engage in sex until after the final treatment as he is still contagious and failure to complete the treatment will lead to a continuation of syphilis and possible life threatening consequences.