Diagnostic Testing
The patient was asked to record daily body temperatures for three weeks
(Figure 2 ). Complete blood count, comprehensive metabolic
panel, liver function tests, thyroid stimulating hormone, erythrocyte
sedimentation rate, C-reactive protein, chest X-ray, urinalysis,
COVID-19 test, and influenza A and B tests were performed. Additionally,
titers for Lyme disease, Anaplasmosis, Hepatitis C, and HIV were
obtained. All were normal or negative, with the following exceptions:
lymphocyte count was low at 780 per mL, monocyte count was elevated at
1302 per mL, inflammatory markers were increased, and 2+ ketones and
trace protein were found on urinalysis. Elevation of inflammatory
markers was perceived to be a non-specific finding. Abnormal lab results
are listed in Table 1 , while normal lab results are listed inSupplemental Table 1 .
At the time of development of palmar rash, antinuclear antibody titer
(ANA) was ordered. Three sets of blood cultures (obtained on different
days) and transthoracic echocardiogram were also performed to exclude
infectious endocarditis. The ANA titer was positive, but all other
studies were normal. As the rash spread, fluorescent treponemal antibody
absorption test (FTA-ABS) and rapid plasma reagin (RPR) test were
ordered, both returning positive. Accordingly, secondary syphilis was
diagnosed.