Cases & Commentaries

Preventable Rash

Commentary By Catherine McLean, MD

The Case

A 35-year-old man with HIV was being followed in
an outpatient internal medicine clinic. At a routine visit,
screening laboratories were checked. The clinic never contacted the
patient about his laboratory test results, and he assumed they were
normal. He returned to his normal lifestyle, including occasional
unprotected sexual activity.

One month later, he developed a rash. The
outpatient clinic was unable to see him immediately, and
recommended he go to the urgent care clinic. The urgent care
provider reviewed his lab results and discovered that his tests for
rapid plasma reagin (RPR) and Treponema antibody were both
positive. Examination was notable for a classic syphilitic rash
(Figure),
confirming the diagnosis of secondary syphilis. The patient was
treated with penicillin in the urgent care clinic. However, he
subsequently developed a Jarisch-Herxheimer
reaction and was admitted to the hospital.

The Commentary

This case highlights the danger of inadequate
follow-up of outpatient tests and the challenges in the recognition
and diagnosis of syphilis and other sexually transmitted diseases
(STDs). Just as important, given a potentially transmissible
disease, the case provides an opportunity to examine the process of
reporting diseases to public health entities and the associated
pitfalls.

Diagnosing Sexually Transmitted
Diseases

Diagnosing untreated syphilis and other STDs can
be complex, even for experienced clinicians. First and foremost,
clinicians must obtain an adequate sexual history. Talking with
patients about their sexual practices is a prerequisite for
assessing their risk for STDs and HIV, for screening appropriately,
and for providing quality care. Data consistently show that sexual
histories are not routinely obtained (1,2), and
few providers have obtained adequate training.(3)

Second, this case underscores the importance of
being familiar with local STD epidemiology. Since 1998, outbreaks
of syphilis have occurred among men having sex with men (MSM) in
cities throughout the United States. Most MSM with syphilis in
these outbreaks have been HIV positive (50%-70%) (4,5), which is
particularly concerning given that co-infection with syphilis and
HIV increases the risk of HIV transmission to a sex
partner.(6)
Understanding the recent epidemiology of syphilis may have
increased this clinician's concern about screening for syphilis in
this patient, possibly resulting in better follow-up.

Third, in order to make the diagnosis,
appropriate screening for STDs must be done on a routine basis.
Many STDs, including syphilis and HIV, are asymptomatic; therefore,
screening asymptomatic patients for STDs is the only way to detect
infection in many patients. The US Preventive Services Task Force
(USPSTF) and the Centers for Disease Control and Prevention's (CDC)
Division of STD Prevention publish STD screening and treatment
guidelines.(7,8) A thorough
sexual history may have identified this patient as a MSM, in which
case, CDC recommends at least annual screening for syphilis,
gonorrhea (urethral, rectal, and pharyngeal), and
chlamydia.(8) The
clinician in this case did order the syphilis serology (the RPR)
but not the syphilis serologic titer, which is critical in
establishing the diagnosis and following the course of the disease
after treatment. We are not provided with information regarding
additional STD screening tests (such as for gonorrhea and
chlamydia); these tests should also have been conducted.

The delay in recognition of this patient's
syphilis infection could have resulted in significant morbidity if
he had developed neurosyphilis, or if one or more sex partners were
infected with syphilis or HIV. Infection with syphilis and other
ulcerative and non-ulcerative STDs increases the risk of HIV
transmission 2- to 5-fold.(6)

Clinician/Laboratory Follow-up

Although the syphilis serology was obtained, the
clinician failed to follow up on the results of the RPR test
ordered, resulting in a delay in the diagnosis of syphilis and
resulting in progression to secondary syphilis. In the "Lost in the
Black Hole" case presented in this journal (9),
Wachter underscored the importance of laboratory follow-up systems
for quality patient care. He recommended laboratory accountability
for reporting critical laboratory results to providers and
suggested the use of reminders for providers to review the results
of ordered laboratory tests.

Health Department Reporting

This case also involves a reportable disease, and
therefore demonstrates one or more possible failures in the system
of reporting communicable diseases to the public health department.
Currently, clinicians are required to report a number of diseases
(for example, shigellosis, malaria, gonorrhea, and tetanus). The
purpose of prompt case reporting of STDs is to insure that: (i)
Persons who are infected are quickly diagnosed and appropriately
treated to control spread of infection; (ii) Partners are notified,
tested, and appropriately treated; (iii) Disease outbreaks are
identified early; and (iv) Local, national, and international
disease surveillance accurately reflects the true burden of disease
in the community [ go to related
site
].(10,11)

What happens when a clinician reports a disease
to the local health department? The health department reporting
process generally works in the following way: Reports are sent by
laboratories and clinicians to the local health department by mail,
email, or fax. Once received, additional demographic and clinical
information is gathered to determine if the diagnosis is accurate,
if treatment was adequate, and if contacts are at risk of infection
or need treatment.

For syphilis, STD experts (Disease Intervention
Specialists [DIS]), using a registry of previous reports of
syphilis and by communicating with other health departments,
determine if a reactive syphilis serology represents a new
infection or a previously treated infection. DIS may contact the
patient to ask about sex partners who may have been exposed to
syphilis. If indicated, DIS will work with patients to determine
how to locate and contact sex partners. While some patients are
initially reluctant to provide this information, this step in the
investigation is important to limit the spread of syphilis and
other STDs.

For patients diagnosed with reportable diseases,
clinicians can help by telling their patients that their infection
is reportable and that the health department may contact them.
Clinicians should ask patients to cooperate with these efforts to
help stop the spread of syphilis in the community. This public
health investigation may improve patient care by locating
difficult-to-find patients (those "lost to follow-up") and by
insuring that adequate treatment is given.

Data from disease case reports (with personal
identifiers removed) are also submitted to the CDC, which collects
information on notifiable diseases and injuries for disease
surveillance and control in the United States. It is estimated that
STD cases reported to CDC represent only 50%-80% of reportable STD
infections in the United States, reflecting limited screening and
low disease reporting.(12) Improved
reporting by both clinicians and laboratories will increase the
number and quality of case reports received by local health
departments and by CDC, improving the accuracy of disease
surveillance data in the United States.

Despite state laws, which typically require
laboratories and clinicians to report reactive syphilis serologies
to local health departments, this case may not have been reported.
If the local health department had been contacted by the
laboratory, a public health investigation may not have been
initiated or conducted in a timely manner. Individual clinicians
and laboratories need to be diligent about reporting diseases that
are reportable in their state to the local health department.

Specific steps to reduce errors include:

  • Ensure there is a mechanism for rapid
    identification and follow-up on positive screening tests.
  • Insure that written protocols about the
    reporting process of state-mandated reportable diseases are
    available and updated as needed.
  • Local health departments should provide
    laboratories and clinicians with reporting feedback through reports
    or newsletters, demonstrating how data collected from case reports
    are used to guide local disease prevention and control activities
    and how clinicians can use this information to guide clinical
    practice.
  • Increase communication between local
    health departments and clincians through updates at hospital grand
    rounds, medical conferences, and through medical societies and
    state licensing boards.
  • Promote electronic laboratory reporting
    to facilitate more timely and accurate reporting where
    feasible.(13)

Part of the challenge is that most systems remain
paper-based and reporting depends on clinicians knowing which
diseases are reportable in the state, where reporting forms are
located, and taking the time to complete and submit the required
documents. An ideal reporting system might be based upon an
electronic laboratory system that flags a positive lab result (eg,
a high titer syphilis serology, or a positive gonococcal culture)
then sends an electronic notice to the clinician requesting
clinical information (including treatment given). This notice would
also serve as a reminder that reporting is required. Ideally, an
electronic reporting system would not rely primarily on the
clinician or laboratory reporting the case but would notify the
local health department at the same time the clinician was notified
and would follow with the additional clinical and treatment
information provided by the clinician. Ideally, an electronic
system such as this would improve care for patients, assist the
clinician with follow-up, and enhance efficiency and completeness
of the public health surveillance system.

Take-Home Points:

  • Obtain sexual histories, know the local
    STD epidemiology, and follow USPSTF and CDC guidelines for
    appropriate STD screening.
  • Assure that there is a mechanism for
    rapid identification and follow-up on positive screening
    tests.
  • Tell patients with a reportable disease
    that the local health department may contact them for additional
    information and encourage your patients to cooperate with this
    process.
  • Exercise your public health
    responsibility to help prevent and control communicable diseases
    through appropriate patient screening, case reporting, and
    collaborative work with your local health department.

Catherine McLean, MD
Medical Epidemiologist
Division of STD Prevention
Centers for Disease Control and Prevention

Resources

U.S. Centers for Disease Control and
Prevention
National STD Hotline
Provides anonymous, confidential information on sexually
transmitted diseases (STDs) and how to prevent them. Also, provides
referrals to clinical and other services.
        English -
800-227-8922 - 24 hours a day, 7 days a week
        Spanish -
800-344-7432 - 8 am to 2 am EST, 7 days a week
        TTY for hearing
impaired - 800-243-7889 - Monday-Friday, 10 am-10 pm
        EST
        DSTD@cdc.gov

CDC's STD
Treatment Guidelines

National
Network of STD/HIV Prevention Training Centers

References

1. Maheux B, Haley N, Rivard M, Gervais A.
STD risk assessment and risk-reduction counseling by recently
trained family physicians. Acad Med. 1995;70:726-8.[ go to PubMed ]

2. Schuster MA, Bell RM, Petersen LP,
Kanouse DE. Communication between adolescents and physicians about
sexual behavior and risk prevention. Arch Pediatr Adolesc Med.
1996;150:906-13.[ go to PubMed ]

3. Bluespruce J, Dodge WT, Grothaus L, et
al. HIV prevention in primary care: impact of a clinical
intervention. AIDS Patient Care STDS. 2001;15:243-53.
[ go to PubMed ]

4. Outbreak of syphilis among men who have
sex with men--Southern California, 2000. MMWR Morb Mortal Wkly Rep.
2001;50:117-20.[ go to PubMed ]

5. Primary and secondary syphilis among men
who have sex with men--New York City, 2001. MMWR Morb Mortal Wkly
Rep. 2002;51:853-6.[ go to PubMed ]

6. Fleming DT, Wasserheit JN. From
epidemiological synergy to public health policy and practice: the
contribution of other sexually transmitted diseases to sexual
transmission of HIV infection. Sex Transm Infect. 1999;75:3-17.[ go to PubMed ]

7. U.S. Preventive Services Task Force.
Guide to clinical preventive services, 2nd ed. Baltimore, MD:
Williams & Wilkins; 1996.

8. Centers for Disease Control and
Prevention. Sexually transmitted diseases treatment guidelines
2002. MMWR. 2002;51(No. RR-6):30-42. Available at:[ go to related site ]. Accessed January 21, 2005.

9. Wachter RM. Lost in the black hole. AHRQ
WebM&M [serial online]. October 2003. Available at: [ go to commentary ].
Accessed January 21, 2005.

10. STD Prevention. Program operations
guidelines for STD prevention: surveillance and data management.
Atlanta, GA: Centers for Disease Control and Prevention;
2002:S-22-S-28. Available at: [ go to related site ]. Accessed January 21, 2005.

11. Sexually transmitted disease
surveillance 2003. Centers for Disease Control and Prevention Web
site. Available at: [ go
to related site
]. Accessed January 21, 2005.

12. Weinstock H, Berman S, Cates W Jr.
Sexually transmitted diseases among American youth: incidence and
prevalence estimates, 2000. Perspect Sex Reprod Health.
2004;36:6-10.[ go to PubMed ]

13. Effler P, Ching-Lee M, Bogard A, Ieong
MC, Nekomoto T, Jernigan D. Statewide system of electronic
notifiable disease reporting from clinical laboratories: comparing
automated reporting with conventional methods. JAMA.
1999;282:1845-50.[ go to PubMed ]

Figure

Figure. Example of Classic Syphilitic
Rash