Case study

When I was on Polk, I had a patient with a CD4<200 who presented with HA x 1wk. She didn't appear toxic and described the headache as more of an annoyance than anything else. Her basic labs were normal, and she was afebrile. Having a low threshold in such a patient, we did an LP which was only remarkable for a minimally elevated protein and no organisms on gram stain. Lacking much to go on, I was about to attribute her symptoms to a tension headache. However, the next morning, I was talking to her and randomly looked down at her hands (image below is from the actual patient, courtesy of the Department of Photo Path at JHH). Look familiar? I sent an RPR & VDRL which were positive--both serum and CSF. Neurosyphilis with a palmar rash! She had a PICC line placed for a 14 day course of IV PCN G. Verging on corny, this case gave me a renewed appreciation for the physical exam.