Question

Case #2

A 72-year old woman has increasing shortness of breath with exertion. At present, she is unable to climb even one flight of stairs without stopping to rest and catch her breath. This symptom started over a year ago and has gradually worsened.

The patient is afebrile with a heart rate of 110/min and a blood pressure of 180/70 mmHg. Cardiac examination reveals a loud diastolic murmur heard along the left sternal border consistent with aortic valve regurgitation. The patient was also noted to have firm, non‐inflamed enlargements of the knees (below). A neurological examination revealed decreased vibratory and light touch sensation in the feet, and the patient was noted to slap her feet on the ground when she walked.

a. This patient likely has syphilis. Explain the complications and why the patient was not previously diagnosed. (2 points)

b. Explain the patient’s clinical presentation with an enlarged knee. What is the pathogenicity (cause) of this condition associated with the etiological agent? (2 points)

c. List one specific test method that would be useful in the final confirmatory diagnosis for this patient. (1 point)

Answer 1

patient was not previously diagnosed because the disease have numerous and complex manifestations, stage specific diagnostic testing which was missed or inappropriately ruled out resulting in devastating cardiovascular and neurologic disease.

   COMPLICATIONS OF SYPHILIS:

• Rubbery lesions on bones, skin, nervous system tissue , arteries of the heart and brain.
• due to these lesions, the patient is susceptible to heart attack, paralysis, blindness, stroke, numbness and dementia
• cannot reverse any permanent damage done to the body by syphilis. though antibiotics can cure a syphilis infection in tertiary stage.

Patient clinical presentation with enlarged knee:

• gradual swelling and pain
• effusion with limited range of motion
• thick, turbid yellow fluid aspiration from the knee.
• microscopy showing large number of white cells.

pathogenicity:

• vaginal or oral sex with someone with syphilis sore
• sharing toilet or swimming pool with an infected person
• The bacteria causing syphilis enters the body through skin or mucus membranes.

confirmatory test:

Nontreponemal tests ( RPR, VDRL). on positive nontreponemal tests, treponemal test (FTA-ABS) was done for confirmation.