1. Case Presentation Professional Practice Group Meeting Judy Gaer City clinic

2. Patient Presentation  Patient is a 26 year old male, HIV +, C/o something that feels like a “cut” on my anus for 5 days. In the last 2 days I can feel a bump there so I think it is a wart and I am here to be treated for the wart.

3. Recent medical history  I had a “bite” on my right upper thigh 7 days ago then the next day I had a similar bite on my left upper thigh. The next day it had spread and I had hives on both my upper legs. I went to the ER and they gave me 1 dose each of Keflex and Erythromycin and gave me a prescription to continue both of them. I never filled the prescription and it went away.

4. Previous Medical History  He gets his HIV care at Tenderloin center. He is not currently on HAART  Medication Allergies: Penicillin-anaphylaxis, Clindamycin, Rifampin and Vancomycin.  Pt had + HSV2 Serology in 2006 He does not specifically remember any sores in his genitals.

5. Sexual History  He is bisexual although he has not had sexual contact with a woman in over a year.  His last sexual exposure was this morning.  He has had 3 new sexual partners in the last 3 months and all are new to him in the last 3 months. He has had oral and anal insertive and receptive sex without condoms with all of them. He has paid money for sex in the last year but not in the last 3 months.  He had sex with an IVDU 1 week ago. He met a partner on the internet 2 weeks ago and had sex with an anonymous partner 3 mos ago. All his partners are HIV positive.

6. Drug use history  He uses Meth intravenously daily.  He uses poppers frequently.  He denies any other drug use in the last 3 months and denies alcohol use.

7. Any Other History you would ask?

8. What would you examine?

9. Exam  Skin tag at anal verge with Ulceration. Ulcer is exquisitely tender. Due to tenderness of ulcer determining if it is indurated is difficult. He has very enlarged groin nodes. No other lymphadenopathy is present. No other lesions or rashes mouth, palms, chest, back or penis. No penile discharge. Pt is circumcised. Testicles WNL.

10. What Tests would you do?

11. Tests  Darkfield was negative but it was a poor sample  RPR was nonreactive  GC and Ct SDA of throat, anus and urine sent.  HSV PCR done of lesion

12. What are the Possible Diagnoses and what would you treat him with?

13. Diagnosis and Treatment  Patient was treated with Doxycycline 100mg 1 po bid for 2 weeks and Acyclovir 400 mg 1po tid x 7days.  Diagnoses: R/O primary syphilis, R/O Herpes

14. Test Results  VDRL Weakly Reactive  TPPA Negative  Hsv Pcr Positive HSV 2  Gc and Ct of Throat, urine and rectum negative  Patient did not return to clinic for follow-up

15. Case 2 49 year old Asian Gay Male HIV negative Seen on 8/14/08. Had an anonymous partner 4 months ago. Denies drug use. Has had 2 partners in the last 3 months. Both are new in the last 3 months. Uses condoms 100% for anal insertive sex. Had unprotected oral insertive sex with both partners. Denies any oral or anal receptive sex. Has sore on penis x 4 days slightly uncomfortable. LSE 7/30/08. He is self treating for the sore with Amoxicillin.

16. What would you examine?

17. EXAM 2 tiny healing lesions on coronal ridge. Lesions are completely closed and dry. No lymph nodes. No penile Dc. Testicles wnl. No rashes or lesions mouth, palms chest or back.

19. What Tests would you do?

20. Tests  Stat RPR nonreactive  VDRL  HSV PCR  HSV Serology  Chlamydia and GC SDA of urine

21. What is your Assessment and Plan?

22. Assessment and Plan A- probable healing HSV P-Acyclovir 400 mg #21

23. Test Results  VDRL Nonreactive  HSV Serology negative  Chlamydia and GC of Urine Negative  HSV Pcr of lesion Negative

24. Patient returned to clinic on 10/7/08. He had 1 new partner since last visit. His LSE was 1 month ago. He has a sore again in the same place. It has been there for 2 weeks.

25. What would you Examine ?

26. Exam Indurated ulcer at coronal ridge, clean based, painless. 1 other almost healed lesion next to it. Enlarged groin nodes bilaterally. No lesions or rashes mouth, palms, chest or back. No penile D/c testicles wnl.

28. What tests would you do?

29. Tests  Darkfield Positive  VDRL  Hsv Serology  Chlamydia and GC SDA of Urine

30. What is your Assessment and treatment?

31. Assessment and Treatment A- Primary Syphilis P- 2.4 MU Bicillin LA, Patient referred to Disease Control Investigator for interview. Return to clinic 1 week for recheck. Patient informed about possible Herxheimer reaction

32. Test Results  VDRL R1:2  Hsv Serology Pending  Chlamydia and GC SDA of Urine Chlamydia positive Gc negative  TPPA Pending  HSV PCR pending