WBR0706

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	USMLE Step 3
Main Category	Primary Care Office
Sub Category	Infectious Disease
Prompt	30 years old white male come to clinic for new hire routine check-up. He has no significant complain. He admits having multiple sexual partners, not using condoms frequently. He didn’t have HIV test before. His past medical history is insignificant. He doesn’t smoke but drink alcohol regularly. His physical examination is insignificant. You ordered HIV and RPR test which turned to be positive. His CD4 is 300 mm3 and RPR titer 1:70. What is the best next step in the management of this patient?
Answer A	Urine culture
Answer A Explanation	Incorrect Urine culture is done in suspected genitourinary infection with urological manifestations.
Answer B	Lumber puncture
Answer B Explanation	Correct This patient present with HIV infection and syphilis of unknown duration, according to CDC recommendation, CSF examination should be done before starting the treatment even in asymptomatic cases, to exclude neurosyphilis
Answer C	Chest X-Ray
Answer C Explanation	Incorrect Chest X-Ray is done only if there are respiratory symptoms
Answer D	Liver function test
Answer D Explanation	Incorrect Liver function test can be done to control the side effect of the antiretroviral treatment
Answer E	Echocardiography
Answer E Explanation	Incorrect Echocardiography can be done to confirm the diagnosis of cardiovascular syphilis
Right Answer	B
Explanation	According to the current CDC recommendation, CSF should be examined before the start of treatment in case of patients diagnosed with syphilis of unknown duration, or late latent syphilis. Patients with CD4 < 350 mm3, and RPR titer greater than 1:32 considered high risk patients for neurosyphilis. Neurosyphilis can present early with CSF changes without neurological manifestations. Educational Objective: References:
Approved	No
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