What is the differential?
Our patient had been treated for syphilis the day before arrival with penicillin. She was suffering from a Jarisch-Herxheimer reaction. This is a reaction to the endotoxin released by the death of spirochetes after treatment of syphilis. It occurs in 50% of patients with primary syphilis and 90% of patients with secondary syphilis.
The reaction is a sepsis mimic because it presents with fever, hypotension, headache, tachycardia, worsening skin rash and tachycardia.
Other diseases caused by spirochetes can cause the same reaction: Lyme disease, relapsing fever, and leptospirosis. It has also been reported after treatment of Q fever, bartonellosis, brucellosis, trichinellosis and African trypanosomiasis.
St. Louis as of 2016 still ranks number one with the highest rates of STDs per capita. It is known as a "condom desert" since fewer stores carry condoms than in most cities in a study done by St. Louis University. Our patient was treated symptomatically with fluids and pain medication with resolution of her symptoms.
Lukehart, S (2017) Syphilis. In Kasper , DL; Fauci, A. Harrisons’ Infectious Diseases (3rd ed) New York: McGraw-Hill p666. ISBN 978-1-259-83579-1
Butler T (2017) The Jarisch-Herxheimer reaction after antibiotic treatment of spirochetal infections: a review of recent cases and our understanding of pathogenesis. Tropical Medicine and Hygiene. 96(1):46-52. PMID 28077740