Right Care at Baptist

Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Dr. Stephen Threlkeld, Baptist Memorial Health Care’s medical director of infectious diseases, contributed to a case study published on Thursday, Jan. 8, 2026, in the prestigious New England Journal of Medicine titled “Case 1-2026: A 50-Year-Old Woman With Fever and Abdominal Pain.”

The case study, published in Vol. 394, No. 2 of the journal, is part of a century-old series called “Case Records of the Massachusetts General Hospital.” It explores clinical cases that challenge physicians.

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Hosts: Jake Lancaster MD, Chief Medical Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Ann Lawson Hobart, Registered Dietician

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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Zachary Nahmias, MD, Dermatologist

Summary:

In this episode of Right Care Baptist, host Dr. Jake Lancaster (Chief Medical Officer, Baptist Medical Group) and Amanda Comer, NP (Chief Advanced Practice Officer) sit down with Dr. Zachary Nahmias, a board-certified dermatologist at NEA Baptist Clinic in Jonesboro, Arkansas, to discuss the most common dermatology referrals from primary care and how to manage them more effectively.

Dr. Nahmias breaks down his top five referral categories — suspicious skin lesions, psoriasis, eczema/contact dermatitis, adult acne, and hard-to-place rashes — and offers practical guidance for each. The conversation covers red flags for skin cancer (flat irregular lesions, bleeding, pain, and the "ugly duckling" that stands out from surrounding spots), when and how to screen patients, and the importance of gathering UV exposure and family history before referring.

The discussion then shifts to rashes, where Dr. Nahmias encourages primary care providers to treat confidently when they recognize common conditions like psoriasis, eczema, and seborrheic dermatitis rather than deferring to a 6-month dermatology wait. He highlights common pitfalls including diagnostic anchoring, the risk of topical steroids masking or feeding fungal infections, the dangers of systemic steroids for psoriasis causing a rebound "whiplash," and misusing high-potency topical steroids in sensitive skin fold areas. He walks through distinguishing tinea from eczema by looking for a leading scale with an erythematous base, and recommends Lotrisone as an underappreciated option when the diagnosis is unclear on the feet and lower legs.

On drug-related rashes, Dr. Nahmias discusses the challenge of identifying culprit medications in patients on multiple drugs, common inpatient offenders like vancomycin and sulfa drugs, and serious reactions including Stevens-Johnson syndrome and DRESS syndrome.

The episode wraps with advice on building relationships with local dermatology offices, taking clinical photos to share with referrals, knowing when to send a patient urgently (vasculitic rashes, sudden whole-body eruptions with systemic symptoms), and how the VisualDx diagnostic platform can help primary care providers narrow differentials and select first-line treatments.

CME Credit Info:

1. Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
2. CME credit is available for up to 3 years after the stated release date

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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Krista Bachert PharmD, System Infectious Disease Lead

CME Credit Info:

1. Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guests: Lia Lansky and Shannon Willoughby

CME Credit Info:

1. Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Stephen Threlkeld MD, Infectious Disease Specialist

CME Credit Info:

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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Alex Yoby, Pharmacist

CME Credit Info:

• Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
• CME credit is available for up to 3 years after the stated release date

Contact [email protected] if you have any questions about claiming credit.

CDC’s Sexually Transmitted Infections (STI) Treatment

Guidelines, 2021

Notable updates:

These guidelines discuss 1) updated recommendations for

treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and

Trichomonas vaginalis; 2) addition of metronidazole to the recommended

treatment regimen for pelvic inflammatory disease; 3) alternative treatment

options for bacterial vaginosis; 4) management of Mycoplasma genitalium;

5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing

among pregnant women; 7) one-time testing for hepatitis C infection; 8)

evaluation of men who have sex with men after sexual assault; and 9) two-step

testing for serologic diagnosis of genital herpes simplex virus

Syphilis

Lore

It is postulated that syphilis came to Europe in the 1490s when Columbus

arrived in Italy from America. After Italy surrendered to the invading French

in 1495, this new disease rapidly spread across Europe. The name

"syphilis" comes from the work of Girolamo Fracastoro, a noted poet

and physician in Verona, Italy. In 1530, he wrote about a shepherd named

Syphilus who angered Apollo, causing the god to curse the entire population

with the affliction that we now know as syphilis

T. pallidum

Syphilis is a systemic, bacterial infection caused by

Treponema pallidum.  Treponema are thin,

Gram-negative, slowly metabolizing spirochetal bacterium, requiring an average

of 30 hours to multiply. It is microaerophilic and cannot grow on standard

culture media. Treponema pallidum’s outer membrane lacks lipopolysaccharides

and has few surface-exposed unique proteins, making it difficult for the immune

system to fight the infection. Because of this characteristic, T

pallidum is labeled as a stealth pathogen. T. pallidum is the

only Treponema species that causes sexually transmitted disease.

Syphilis is characterized by a wide range of variable

clinical symptoms that can resemble other diseases, which make it difficult to

diagnose without a test, therefore, it is often referred to as “The Great

Imitator”. The infection progresses through multiple stages (primary,

secondary, latent, and tertiary) and can affect virtually every organ system in

the body, even many years or even decades after the original infection.

Infected people are contagious during the primary and secondary stages of

syphilis.

Stages of syphilis

Primary syphilis: Primary syphilis classically

presents as a single painless ulcer or chancre at the site of infection but can

also present with multiple, atypical, or painful lesions. A chancre is defined

as a firm, round, painless ulcer at the site of entry of an infecting organism.

Chancres appear 10 to 90 days (median of 21 to 25 days) after exposure to the

infecting organism. While the chancre represents the initial local reaction to

the infection, the bacteria quickly become widely disseminated in the body,

including the cerebrospinal fluid, even without any additional immediate

symptoms. Up to 70% of early syphilis patients will demonstrate cerebrospinal

fluid (CSF) changes consistent with neurosyphilis, and 30% will have direct

evidence of T pallidum.  Despite this occurrence, very few will develop

clinical neurosyphilis.

Secondary syphilis: A diffuse and extensive

maculopapular rash that includes the palms of the hands and the soles of the

feet, as well as oral lesions in the mouth, are the characteristic cutaneous

manifestations of secondary syphilis. Symptoms typically appear 2 to 8 weeks

after the disappearance of the primary chancre and have multiple systemic

manifestations that can involve any system or body part. The T pallidum multiply

and spread rapidly, causing fevers, myalgias, headaches, anorexia, sore throat,

weight loss, joint pain, malaise, and particularly, the cutaneous

manifestations characteristic of secondary syphilis. Enlarged lymph nodes

are common in this stage and are usually described as firm, rubbery, and with

only minimal tenderness. The lesions of secondary syphilis generally resolve

within a few weeks, even without treatment, but will relapse in 25% of

untreated patients, usually within 12 months. After that, without treatment,

the disease enters the latent stage, and about 33% of patients will eventually

develop tertiary syphilis.

Tertiary syphilis: Late symptomatic disease that can

manifest months, years, or even decades after the initial infection as

cardiovascular syphilis (aortic aneurysm, aortic valvulopathy), neurosyphilis

(meningitis, hemiplegia, stroke, aphasia, seizures, spinal neuroarthropathy,

tabes dorsalis, syphilitic paresis), or gummatous syphilis (infiltration of any

organ and its subsequent destruction).

Latent syphilis: Latent syphilis is defined as

syphilis characterized by seroreactivity without other evidence of primary,

secondary, or tertiary disease. Latent infections (i.e., those lacking clinical

manifestations) are detected by serologic testing. Latent syphilis acquired

within the preceding year is referred to as early latent syphilis; all other

cases of latent syphilis are classified as late latent syphilis or latent

syphilis of unknown duration. Latent syphilis is not transmitted sexually

Neurosyphilis: T. pallidum can infect the CNS, which

can occur at any stage of syphilis and result in neurosyphilis. Early

neurologic clinical manifestations or syphilitic meningitis (e.g., cranial

nerve dysfunction, meningitis, meningovascular syphilis, stroke, and acute

altered mental status) are usually present within the first few months or years

of infection. Late neurologic manifestations (e.g., tabes dorsalis and general

paresis) occur 10 to >30 years after infection.

Congenital syphilis: Congenital syphilis results from

transplacental transmission or contact with infectious lesions during birth and

can be acquired at any stage, often causing stillbirth or neonatal

congenital infections. Without treatment, up to 40% of women with syphilis will

have stillborn births, and many more will have premature labor or

low-birth-weight babies.

Effective prevention and detection of congenital syphilis

depends on identifying syphilis among pregnant women and, therefore, on the

routine serologic screening of pregnant women during the first prenatal visit

and at 28 weeks’ gestation and at delivery for women who live in communities

with high rates of syphilis, women with HIV infection, or those who are at

increased risk for syphilis acquisition. Certain states have recommended

screening three times during pregnancy for all women; clinicians should screen

according to their state’s guidelines.

Epidemiology

Per the CDC, a syphilis

epidemic is occurring in the United States, with sustained increases in primary

and secondary syphilis from 5,979 cases reported in 2000 to 133,945 cases

reported in 2020, a 2,140% increase

The rate of reported congenital syphilis in the United

States has increased dramatically since 2012.

About 53 percent of congenital syphilis is reported from

southern states, according to data from the U.S. Centers for Disease Control

and Prevention.

3,761 cases of

congenital syphilis in the United States were reported to CDC in 2022.

including 231(6%) stillbirths and 51(1%) infant deaths. 88% of cases of

congenital syphilis in 2022 were directly impacted by the lack of timely

testing and adequate treatment during pregnancy.

·        

MISSISSIPPI: In 2022, Mississippi ranked 5th in

reported rates of primary and secondary syphilis with a rate of 31.1 per

100,000 individuals (the rate was 28.1 per 100,000 individuals in 2021).

Mississippi also ranked 6th in reported rates of congenital syphilis with a

rate of 207.6 per 100,000 live births (the rate was 182.0 per 100,000 live

births in 2021).

·        

ARKANSAS: In 2017, only 27 pregnant women with

reported syphilis, and 13 congential syphilis cases per the State Health

Department Data Hub. Rates have steadily increased since, now in 2023, 104

pregnant women, with 64 reported congenital syphilis cases. 1,426 syphilis

cases were reported in 2023.

·        

TENNESSEE: In Tennessee, Syphilis has increased 162%

from 2017 to 2022 (950 to 3813 cases). Syphilis among women has increased 311%

from 2017 to 2022 (290 to 1191 cases). Congenital syphilis has increased >400%

from 2017 to 2022 (11 to 61 cases). Per TN Dept of Health

Diagnosis

Who and when do we test?

Syphilis testing should be performed on patients with signs

or symptoms of infection, as well as asymptomatic patients at high risk for

infection or for transmitting to others. In TN, AR, and MS, testing during

pregnancy is REQUIRED by law. Any woman who has a fetal death after 20 weeks’ gestation should be

tested for syphilis. No mother or neonate should leave the hospital without

maternal serologic status having been Recommendations and Reports 50 MMWR /

July 23, 2021 / Vol. 70 / No. 4 US Department of Health and Human

Services/Centers for Disease Control and Prevention documented at least once

during pregnancy. Any woman who at the time of delivery has no prenatal care

history or has been at risk for syphilis acquisition during pregnancy (e.g.,

misuses drugs; has had another STI during pregnancy; or has had multiple sex

partners, a new partner, or a partner with an STI) should have the results of a

syphilis serologic test documented before discharge.

REQUIRED IN MS: In April of 2023, syphilis testing during

pregnancy was made a requirement for pregnant people in their first trimester,

third trimester, and at delivery as a part of Mississippi’s efforts to prevent

congenital syphilis in infants. Per MS Dept of Health

REQUIRED IN AR: Arkansas law requires syphilis testing during the first prenatal visit

and during the 3rd trimester (between 28-32 weeks of pregnancy).

Testing at delivery is required if not done during the pregnancy. Per AR Dept

of Health

REQUIRED IN TN:

Currently, state law requires all pregnancies be tested for syphilis in the 1st

trimester or at the 1st prenatal care visit. Rescreening for

syphilis at 28-32 weeks gestation and at delivery is highly encouraged by TDH

for ALL patients, regardless of first trimester test results. Per TN Dept of

Health

Do we test for cure?

Yes, at six and 12 months after treatment, patients with

primary syphilis should be reexamined and undergo repeat serologic testing.

Testing

Consists of dark-field microscopy and serum, tissue, or CSF

serological testing. Darkfield microscopy and polymerase chain reaction (PCR)

assays for T pallidum are not generally available in the US, and

silver-staining techniques are considered unreliable.[19] Nucleic acid

amplification tests (NAATs) can be clinically helpful but have not been

approved by the FDA for use in the US.[139][144] Therefore,

serological testing is the preferred primary diagnostic modality for syphilis. Serological

testing for syphilis is classified as either nontreponemal or

treponemal. The tradition algorithm for diagnosing syphilis is to screen with a

non-treponemal test and then if the non-treponemal test is reactive, verify

with a specific tests such as the FTA-abs, TPHA, MHATP, or ELISA. Use of only

one type of serologic test (non-treponemal or treponemal) is insufficient for

diagnosis and can result in false-negative results among persons tested during

primary syphilis and false-positive results among persons without syphilis or

previously treated syphilis

New guidelines for testing in February 2024 -> CDC

Laboratory Recommendations for Syphilis Testing, United States, 2024

Laboratories have a critical role in the public health

response to the syphilis epidemic. The responsibility of the laboratory is to

test specimens and report results in a timely manner, allowing clinicians to

efficiently make clinical diagnoses for patient management. Public health

reporting by laboratories also allows local health departments and CDC to

conduct surveillance and monitor disease trends. This report details CDC’s new

recommendations for syphilis testing, including laboratory-based tests, point-of-care

(POC) tests, processing of samples, and reporting of test results to aid

laboratorians and clinicians in the diagnosis of syphilis. Future revisions to

these recommendations will be based on new research or technologic advancements

for syphilis clinical laboratory science.

Traditional algorithm: The traditional algorithm for syphilis serologic screening begins with a

nontreponemal (lipoidal antigen) test, and any reactive specimens are tested

for confirmation by a treponemal test. This sequence has been widely used for

decades because nontreponemal (lipoidal antigen) tests were relatively

inexpensive and treponemal tests were manual, labor intensive, more costly, and

limited in number.

Reverse sequence algorithm: However, automated treponemal immunoassays, which were originally

cleared by FDA for blood bank screening, are now cleared by FDA for clinical

screening, leading to the reverse sequence algorithm. Initial screening with an

automated treponemal test of a sample with a positive result must be followed

by a quantitative nontreponemal (lipoidal antigen) test. When the reverse

sequence algorithm is used, any discordant results should be adjudicated by a

second treponemal assay (e.g., TPPA) that has a different format and includes

different antigens (85).

Each algorithm

has advantages and disadvantages and both are acceptable. The traditional

algorithm might be less sensitive in detecting early or late latent syphilis,

although an increase in false positives might occur when applying the reverse

algorithm in low-prevalence populations

The way that Baptist has chosen is to do antibody testing

first, then if positive reflex to RPR-> If discordant, do another test

Nontreponemal Tests

Nontreponemal tests for syphilis (venereal

disease research laboratory [VDRL] and rapid plasma reagin [RPR]) are screening

examinations that detect IgG and IgM antibodies to the patient's cardiolipin

that have become integrated with the T pallidum bacteria in

the blood or CSF and are therefore not specific for syphilis. The VDRL and RPR

tests are only positive after the development of the primary chancre. By the

tertiary (late) stages of syphilis, VDRL titers are usually low or

undetectable. These tests are relatively inexpensive and simple but somewhat

time-consuming to perform as they require a trained laboratory technician. Patients

with a reactive nontreponemal test should always receive a treponemal test to

confirm the syphilis diagnosis.

RPR and VDRL tests are still the primary screening methods

used in public health laboratories in the United States

Can’t interchange RPR and VDRL, example if mom gets RPR,

baby needs to get RPR. Why?

 Regardless of which

test method is applied, serum antibody titers from RPR, VDRL, and other

nontreponemal (lipoidal antigen) tests should not be used interchangeably to

manage patients because they are different test methods and the subjective

titer results can vary by laboratory. Therefore, patient specimens should be

tested using the same nontreponemal (lipoidal antigen) test method and specimen

type.

Treponemal Tests

Treponemal antibody tests (fluorescent treponemal antibody

absorption assay [FTA-ABS], T pallidum particle agglutination assay [TPPA], T

pallidum hemagglutination assay [TPHA], chemiluminescent immunoassay [CIA],

enzyme immunoassay [EIA], and rapid chromatographic immunoassays) that detect

specific serum antibodies to T pallidum are considered necessary and required

for a confirmed diagnosis of syphilis when the VDRL or RPR tests are initially

positive. Of these, the most sensitive and preferred confirmatory treponemal

antibody tests would be the FTA-ABS or the TPPA for all syphilis stages, where

available, although the TPPA is considered more specific. The majority of

patients who have reactive treponemal tests will have reactive tests for the

remainder of their lives, regardless of adequate treatment or disease activity.

Reason why need both

tests?

Combination of both tests can give us ability to accurately

stage. To diagnose syphilis accurately, you must utilize both treponemal and

nontreponemal tests since they detect different aspects of the infection,

providing...

Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guests:

1. Sharon Huerta RN - Heart Failure Specialist
2. Amy Brewster PharmD

CME Credit Info:

• Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
• CME credit is available for up to 3 years after the stated release date

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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Blake Daniels MD, Anesthesiologist

CME Credit Info:

• Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
• CME credit is available for up to 3 years after the stated release date

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Hosts: Jake Lancaster MD, Chief Medical Information Officer and Amanda Comer DNP, System Director, Advanced Practice Providers

Guest: Krista Bachert PharmD, System Infectious Disease Lead

CME Credit Info:

• Link to complete brief survey and claim CME credit: https://www.surveymonkey.com/r/C55LKSY
• CME credit is available for up to 3 years after the stated release date

Contact [email protected] if you have any questions about claiming credit.