[Question #13489] Syphilis/HIV evaluation
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3 days ago
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Hey Dr, I had a possible exposure—protected oral and vaginal sex with a lower-standard CSW (not an escort type). Condom appeared intact; I declined her offer for condomless services. Later learned she was rumored to have transmitted HIV/HSV to another client. At 49 days post-exposure, I noticed a possible chancre: a light pink, penny-sized lesion halfway up the side of my scrotum between the thigh—an odd spot for skin-to-skin contact with a syphilis sore. It looks like an early chancre minus ulceration; however, I often scratch this area due to itching, so it might be an abrasion from that habit. My tests: day 17 HIV RNA, HSV, RPR (syphilis), and Hep —all negative; day 32 HIV 4th gen and HSV —negative; day 41 HIV RNA, HSV, RPR (syphilis) and Hep —all negative.What’s your evaluation? Syphillis is now my primary concern.
Thank you in advance.
Thank you in advance.
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Edward W. Hook M.D.
3 days ago
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Welcome to our Forum. Thanks for your questions. I'll be glad to comment. Even before we consider your laboratory tests, your risk of syphilis was low. Infectious syphilis rates among lower-standard CSWs are low, typically less than 5%, less that 1/3 of unprotected exposures to syphilis infected partners result in infection, and condoms markedly reduce risk for all STIs including syphilis. Further, as you point out, the location of your lesion would be quite unusual for syphilis and a syphilitic chancre would not appear this long after an exposure. Then, when you add consideration of your lab tests you can be entirely confident that you do not have syphilis, or HIV. Herpes is more difficult to diagnose but nothing you describe suggests HSV either.
I would look for other causes of the lesion you describe. Fungal sores can take the appearance you describe, as can bacterial skin infections or a number of non-STI dermatological processes..
Please don't worry- I am confident that the lesions you describe is not syphilis and that you do not have HIV. EWH
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3 days ago
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Thank you for your timely reply
1-From your experience, how common is a syphilis chancre on the scrotum? 2-What is the typical timeline you’ve observed syphilis follow? 3- Regarding HSV, my understanding is symptoms usually appear within 2–12 days; would I be in the clear after that window? 4- Could the mark be scar tissue or a small scab? It has defined borders but an irregular, slightly asymmetrical shape — not a perfect circle — and I suspect it’s from scratching or a minor abrasion.
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Edward W. Hook M.D.
3 days ago
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1-From your experience, how common is a syphilis chancre on the scrotum?
Rare. i can't provide a specific percentage but in my over 40 years of practice I've seen or heard of perhaps one or two.
2-What is the typical timeline you’ve observed syphilis follow?
On average an initial syphilis lesion would appear by day 21 and certainly by day 30-35.
3- Regarding HSV, my understanding is symptoms usually appear within 2–12 days; would I be in the clear after that window?
Correct. If the lesion did n't appear until more than 10 days after your exposure, it is NOT syphilis.
4- Could the mark be scar tissue or a small scab? It has defined borders but an irregular, slightly asymmetrical shape — not a perfect circle — and I suspect it’s from scratching or a minor abrasion.
It really doesn't sound like a scab. It could be a scrape or something else. If you really want to know, you should ask an experienced clinician to take a look
EWH
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