Treponema pallidum (Syphilis) Quiz: Ace Your Exams

A 55-year-old woman comes to her primary care physician for evaluation of exertional dyspnea and difficulty with ambulation. She has not experienced chest pain, syncope, or loss of consciousness but states she cannot climb a flight of stairs without feeling winded. She also reports gait instability and difficulty keeping her balance while standing. Past medical history is significant for hypertension, diabetes, untreated HIV, and chronic hepatitis C infection. Current medications include metformin, lisinopril, and glyburide. The patient is not sexually active and is post-menopausal. She lives in Connecticut with her niece and went on a camping trip six weeks ago. The patient does not use tobacco, alcohol, or recreational drugs. Temperature is 37.0°C (98.6°F), pulse is 90/min, respirations are 20/min, and blood pressure is 160/65 mmHg. Physical examination reveals granulomatous lesions with heaped borders on the patient’s lips, right leg, and arm. On cardiac auscultation, the apical impulse is displaced laterally and inferiorly with the presence of an early diastolic murmur over the left sternal border. The abdomen is soft and nontender. External genital examination reveals multiple wart-like lesions on the labia majora. Cervical motion tenderness is absent on bimanual examination. Neurological examination reveals a positive Romberg sign and loss of vibration perception with intact motor function. Ophthalmic examination is notable for an absent light reflex with a retained accommodation reflex. Which of the following historical features is the most likely etiology of this patient's current condition?