What is the appropriate management for a female patient with general weakness, oral and genital ulcers, and decreased appetite, suspected of having sexually transmitted infections (STIs) including Human Immunodeficiency Virus (HIV), Herpes Simplex Virus (HSV), and syphilis?

Management of Female Sex Worker with General Weakness, Oral and Genital Ulcers, and Decreased Appetite

This patient requires immediate comprehensive STI testing including serologic testing for syphilis, HIV testing, HSV culture or antigen testing from ulcer sites, and empiric treatment for both syphilis and HSV while awaiting results, given the high-risk presentation with both oral and genital ulcers suggesting possible secondary syphilis. 1

Immediate Diagnostic Workup

The presence of both oral and genital ulcers in a high-risk patient is highly suggestive of secondary syphilis, which represents disseminated disease and requires urgent diagnosis and treatment to prevent devastating neurologic and cardiovascular complications. 2

Required laboratory testing includes:

• Serologic test for syphilis (RPR or VDRL) - mandatory for all patients with genital ulcers, with 90% of primary syphilis cases showing positive titers 1, 3
• HIV testing - must be performed immediately given the high-risk exposure and the fact that genital ulcers facilitate HIV transmission 1, 4
• HSV culture or antigen test from both oral and genital ulcer bases - HSV remains the most common cause of genital ulcers (49% prevalence) and can cause severe mucosal disease 1, 3
• Darkfield examination or direct immunofluorescence for Treponema pallidum if available 1
• Culture for Haemophilus ducreyi if chancroid is endemic in your area 1

Empiric Treatment Strategy

Because clinical diagnosis alone is neither sensitive nor specific, and up to 10% of patients have co-infections (such as HSV with syphilis), empiric treatment must cover multiple pathogens while awaiting test results. 1, 2

For Suspected Syphilis (Primary Treatment Priority)

Given the multiple ulcers in both oral and genital sites, treat empirically for syphilis:

• Benzathine penicillin G 2.4 million units IM in a single dose for primary, secondary, or early latent syphilis 3
• If the diagnosis is unclear but syphilis cannot be excluded, many experts recommend treating for syphilis empirically 1

For HSV (Concurrent Treatment)

• Acyclovir 400 mg orally 5 times daily for 10 days for initial genital herpes 5, 6
• Alternative: Acyclovir 200 mg every 4 hours, 5 times daily for 10 days 6
• Ensure adequate hydration during acyclovir therapy 6

For Chancroid (If Endemic in Your Area)

• Azithromycin 1 g orally in a single dose, OR 1
• Ceftriaxone 250 mg IM in a single dose 1

Critical Management Considerations

HIV Co-infection Impact

• HIV-positive patients with genital ulcers have slower healing, higher treatment failure rates, and may require prolonged therapy courses 1, 5
• If HIV testing is positive, use the erythromycin 7-day regimen (500 mg orally 4 times daily) for chancroid with close follow-up 1, 5
• HIV-infected patients may present with more aggressive secondary syphilis and increased rates of early neurological involvement 4
• Syphilis and HIV dramatically enhance transmission of each other through increased genital ulceration 4

Co-infection Recognition

• 10% of patients with genital ulcers have co-infections (HSV with syphilis, or chancroid with T. pallidum) 5, 2
• Do not assume a single pathogen - treat empirically for multiple etiologies when diagnosis is uncertain 5

Follow-up Protocol

• Re-examine at 3-7 days after initiating therapy to assess for symptomatic and objective improvement 1, 5
• If treatment is successful, ulcers should improve symptomatically within 3 days and objectively within 7 days 1, 5
• Repeat HIV and syphilis testing at 3 months if initial results are negative 1, 5
• Large ulcers may require more than 2 weeks for complete healing even with appropriate therapy 1, 5

Management of General Weakness and Decreased Appetite

The constitutional symptoms (general weakness, decreased appetite) suggest:

• Possible secondary syphilis - systemic symptoms are common with disseminated disease 2
• Possible acute HIV infection - if this represents primary HIV with concurrent STI 4, 7
• Nutritional support and symptomatic management while treating underlying infections 1

Critical Pitfalls to Avoid

• Do not delay empiric treatment while awaiting test results - clinical diagnosis alone is inaccurate, but waiting for results can lead to disease progression 1, 2
• Do not assume single pathogen - up to 25% of genital ulcers remain undiagnosed even after complete evaluation, and co-infections occur in 10-17% of cases 5, 2
• Do not continue empiric antibiotics indefinitely without establishing a diagnosis - obtain tissue diagnosis after 7 days of treatment failure 5
• Do not miss HIV testing - genital ulcers facilitate HIV transmission and may indicate high-risk behavior requiring immediate intervention 1, 5, 4

Partner Management

• Treat all sexual contacts within 10 days before symptom onset empirically, regardless of whether symptoms are present 1, 5
• Counsel patient to avoid sexual contact until ulcers are completely healed and treatment is completed 6