A 30 y.o. woman with HIV and lupus was treated for a rash on the day pta. She now presents with fevers, myalgias and worsening rash.

What is the differential?

jar.jpg
jar2.jpg

 

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.

 

 secondary syphilis of the tongue

secondary syphilis of the tongue

 primary syphilis of the tongue

primary syphilis of the tongue

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