Table 1.

Case timeline

Date	Venue	Summary	Diagnostic test results	Intervention
19 December 2013	Emergency Department	37-y-old man with HIV presents with 3–4 w of anal pain	Examination: anal ulcer	Psyllium; zinc oxide; dibucaine cream
6 January 2014	Emergency Department	Anal pain and subjective fevers	Examination: anal ulcer	Surgical consult; cephalexin
9 January 2014	Surgery center	Anal pain but fevers resolved	Examination: under anesthesia, anal ulcer	Cultures; punch biopsies
11 January 2014	Emergency Department	Nausea and vomiting	Examination: anal ulcer; inguinal adenopathy; creatinine 1.4; +3 protein; alanine transaminase 255; alkaline phosphatase 881; bilirubin 1.1; abdominal ultrasound	Hospitalization; hydration; switch to trimethoprim/sulfamethoxazole on basis of culture results
13 January 2014	Hospital	Nausea and vomiting resolved	Creatinine 1.58; urine protein/creatinine 8.2; rapid plasma reagin 1:16	Nephrology, Gastroenterology, Infectious Disease consults; switch to penicillin
16 January 2014	Hospital	Asymptomatic	Renal biopsy	None
2 February 2014	Nephrology clinic	Asymptomatic	Creatinine 0.99; urine protein/creatinine < 0.13; alanine transaminase 62; alkaline phosphatase 265	Prescribed to complete total of 3 w of penicillin therapy
6 March 2014	Nephrology clinic	Asymptomatic	Creatinine 0.88; urine protein/creatinine < 0.15; alanine transaminase 50; alkaline phosphatase 96	None