What is the most appropriate management for a 21-year-old woman with suspected secondary syphilis, presenting with a rash on her trunk, hands, and feet, swollen lymph nodes, and a history of a genital sore, who is leaving the state the next morning and will be unable to return for follow-up?

Management of Secondary Syphilis in a Patient Leaving the State

The most appropriate management for this patient with secondary syphilis is intramuscular administration of benzathine penicillin G 2.4 million units as a single dose. 1, 2

Clinical Presentation Analysis

This patient presents with classic signs of secondary syphilis:

• Red rash on trunk, hands, and feet (including palms and soles)
• Swollen lymph nodes in neck and groin
• Oral ulcers
• History of genital sore 6 weeks ago
• Fever (101°F)

These findings strongly indicate secondary syphilis, which typically appears 4-10 weeks after the primary chancre (the genital sore the patient noticed).

Treatment Rationale

• Benzathine penicillin G 2.4 million units IM as a single dose is the gold standard treatment for early syphilis (primary, secondary, and early latent) 1, 2
• This is particularly important for this patient who:
  • Is leaving the state the next day
  • Will not be available for follow-up
  • Needs definitive treatment before departure

Alternative Options Analysis

1. Acyclovir: Inappropriate as it treats viral infections, not bacterial infections like syphilis 2

2. Diphenhydramine/prednisone/hydrocortisone: These would only provide symptomatic relief without addressing the underlying infection 2

3. Acetaminophen and increased fluid intake: Supportive care only, would not treat the infection 2

4. Doxycycline: While doxycycline 100mg orally twice daily for 14 days is an acceptable alternative for penicillin-allergic patients 2, 3, it is not ideal in this case because:

   • The patient is leaving town and compliance with a 14-day regimen cannot be assured
   • Single-dose penicillin provides immediate effective treatment

Special Considerations

• Patient mobility: The single-dose penicillin regimen is ideal for patients who may be lost to follow-up 1
• Disease stage: Secondary syphilis is highly infectious, making immediate treatment crucial to prevent transmission 4
• Follow-up: Ideally, the patient should be advised to:
  • Have follow-up serologic testing at 3,6, and 12 months 2
  • Be tested for HIV due to high co-infection rates 2

Potential Adverse Effects

• Injection site pain can occur with benzathine penicillin G administration 5
• Jarisch-Herxheimer reaction (fever, headache, myalgia) may occur within 24 hours of treatment due to spirochete die-off 2
• Patient should be warned about these potential reactions before leaving

Conclusion

For a patient with secondary syphilis who is leaving the state the next day with no possibility of follow-up, intramuscular benzathine penicillin G 2.4 million units as a single dose is the most appropriate management strategy, providing definitive treatment in a single visit.