Patient with Syphilis, Gonorrhea, and Asymptomatic Anorectal Chlamydia

Introduction: 

Diagnosing Lymphogranuloma Venereum (LGV) is a challenge in the absence of routinely available serovar-specific Chlamydia trachomatis (Ct) tests.

Case Description: 

A 23 year old presented to STD clinic with urethral discharge four days after his last episode of unprotected insertive and receptive anal sex.  He was presumptively treated for gonorrhea (GC) and Ct with Ceftriaxone 250 mg and Azithromycin 1 gram.  Specimens for anorectal and urethral GC/Ct testing were collected, as was blood for syphilis and acute HIV testing.  Rapid HIV test was negative. 

The RPR titer from the first visit was 1:128; the patient returned to clinic five days later for treatment with Bicillin 2.4 Million Units (BIC).  The discharge was gone.  Anorectal NAAT results were not yet available. Urethral Nucleic Acid Amplification Testing (NAAT) was positive for GC. 

He returned nine days later for a second BIC.  The anorectal Ct/GC NAATs from his first visit were positive. He reported no new exposure and was not treated for Ct or GC. 

Three weeks later he was admitted to the hospital with severe lower abdominal pain.  MRI and laparoscopy showed extensive abdominal adenopathy.  No biopsy was performed.   Fever developed on the second hospital day.  The Infectious Disease (ID) consultant diagnosed acute HIV.  HIV viral load was in the millions. The ID consultant called the Bureau of STD Control (BSTDC) for advice on syphilis treatment and was informed that the patient had been diagnosed with anorectal Ct infection, but had not been treated for LGV. The specimen from the first visit was sent to a reference laboratory for serovar testing and was positive for the L-2 serovar of Ct.

Discussion:  

This patient presented with GC urethritis, syphilis, asymptomatic anorectal LGV and gonorrhea.  He developed acute HIV infection, and abdominal pain which may have been caused by untreated LGV.