A 37-Year-Old Man with a Rash

This case report details a 37-year-old man presenting with a progressive, morbilliform rash affecting the palms, soles, and trunk, accompanied by throat tightness, fatigue, night sweats, GI symptoms, and mild dyspnea. Initial suspicion included vaccine reaction and drug eruption, but the rash's distribution, systemic symptoms, elevated globulin gap, and lymphadenopathy prompted further testing. Serologic and nucleic acid assays confirmed HIV-1 infection (RNA: 3.4 million copies/mL, CD4: 700/μL) and secondary syphilis (RPR: 1:8), likely acquired during a recently ended relationship. Treated with intramuscular benzathine penicillin and antiretroviral therapy (bictegravir, tenofovir alafenamide, emtricitabine), the patient developed transient fever consistent with a Jarisch–Herxheimer reaction. Despite clinical stabilization, follow-up was limited due to financial barriers. The case emphasizes importance of nuanced sexual history, early serologic testing, and public health implications of access to PrEP and HIV care.

This case report details a 37-year-old man presenting with a progressive, morbilliform rash affecting the palms, soles, and trunk, accompanied by throat tightness, fatigue, night sweats, GI symptoms, and mild dyspnea. Initial suspicion included vaccine reaction and drug eruption, but the rash's distribution, systemic symptoms, elevated globulin gap, and lymphadenopathy prompted further testing. Serologic and nucleic acid assays confirmed HIV-1 infection (RNA: 3.4 million copies/mL, CD4: 700/μL) and secondary syphilis (RPR: 1:8), likely acquired during a recently ended relationship. Treated with intramuscular benzathine penicillin and antiretroviral therapy (bictegravir, tenofovir alafenamide, emtricitabine), the patient developed transient fever consistent with a Jarisch–Herxheimer reaction. Despite clinical stabilization, follow-up was limited due to financial barriers. The case emphasizes importance of nuanced sexual history, early serologic testing, and public health implications of access to PrEP and HIV care.