A 33-year-old man was admitted to the hospital with a two-week history of fever, chills, arthralgias,
malaise, anorexia, and a generalized non-pruritic erythematous rash. He also noted several days of
blurring of vision in his right eye. Pertinent findings on physical examination included a temperature
of 38° C, generalized lymphadenopathy, hepatosplenomegaly, and a maculopapular rash involving his
face, trunk, and extremities, including his palms and soles. Ophthalmologic examination of his right eye
revealed a posterior placoid chorioretinitis. Laboratory findings were notable for a lymphocytosis with
increased Th17 and Th22 cells and markedly elevated liver enzymes. A liver biopsy showed bile canaliculi
heavily colonized by spirochetes. Cerebrospinal fluid analysis revealed a mononuclear pleocytosis and
a positive FTA-ABS test. Dark-field microscopy of a skin scaping was positive for Treponema pallidum.
The patient was diagnosed with secondary syphilis with neurological involvement. He was treated with
intravenous penicillin G for 14 days, during which he experienced a transient Jarisch–Herxheimer
reaction. The patient was discharged in stable condition with plans for long-term serologic monitoring.
