After Unprotected Sex, 50-Year-Old Has Rash, Severe Weakness

Amber M. Bokhari, MD


August 22, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 50-year-old man presents with a 1-month history of oral thrush, skin rash, significant weight loss, diarrhea, and severe weakness. He has been febrile, with malaise, shortness of breath, and a dry cough for 5 days. He also has intermittent dull headaches and neck stiffness without any focal signs.

The patient is unhoused and has not sought medical care for decades. He has not been diagnosed with HIV infection, hepatitis, or any other condition. His clothes are soiled and in poor condition. During the past year, he has lost a significant amount of weight and appears cachectic. He has multiple sex partners and does not use any protection during sexual intercourse. He reports using crack cocaine but does not report intravenous (IV) drug use. When he is able to obtain cigarettes, he smokes about one pack a day.