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1. Several weeks ago, this 56-year-old man noticed numerous asymptomatic round macules and papules on his palms and soles, many with scaly peripheral margins. Similar lesions are noted on the penile corona and glans. There is a faint but definite morbiliform, blanchable pink rash covering most of the patient’s trunk, taking on a “shawl” distribution across the shoulders. The patient is exclusively homosexual and recently engaged in high-risk sexual activity.
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Diagnosis: It would be hard to imagine a more classic example of secondary syphilis than was seen in this case, occurring in a patient so obviously at risk. But it’s only “obvious” if you’re ready and aware of how syphilis manifests. It also helps if you understand how common it is and who’s likely to get it.
TAKE-HOME LEARNING POINTS
• Palmar and plantar rashes are unusual and should prompt the examiner to expand the history and physical.
• Secondary syphilis, though uncommon, is far from rare, especially among gay men engaging in high-risk sexual behavior.
• It’s common for the patient to deny the appearance of the chancre of primary syphilis, and such a lesion would be long gone by the time those of secondary syphilis manifest.
• Conditions involving the skin should be seen by a dermatology provider, regardless of location. This includes diseases of the skin, hair, nails, oral mucosa, genitals, feet, or palms. One potential exception is the eye itself, though most diseases “of the eye” are, in reality, diseases of the periocular skin—and belong with a dermatology provider.
For more information on this case, see “When There’s More to the Story ….” Clin Rev. 2013;12;2013(12):W2.
For the next photograph, proceed to the next page >>
2. First appearing a month ago, this rash was first confined to the patient’s abdomen and subsequently spread. The blanchable, erythematous papules and nodules are fairly dense, uniformly covering most of his skin but sparing face and soles. Two 7-mm scaly brown nodules are seen on his right palm. There are no palpable nodes in the usual locations. More than 10 years ago, the patient was diagnosed with HIV, which is well controlled with medication. Homosexually active, he denies having any new contacts.
Diagnosis: This case presents a fairly typical clinical picture of secondary syphilis—a diagnosis that requires confirmation with syphilis serology: rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) testing. The latter measures antibodies to the lipids formed by the host against lipids formed on the treponemal cell surface.
In this case, the diagnosis had to be confirmed by more specific treponemal tests, usually conducted by the local health department, to which positive results must be reported. If further testing confirms the diagnosis (as expected), the patient will be treated by the health department. Investigators will question him, attempting to determine the source of the infection and thereby quell an outbreak.
For more information on this case, see “Unusual Cause for Asymptomatic Rash.” Clin Rev. 2013;23(9):W6.
For the next photograph, proceed to the next page >>
3. A 43-year-old man presented with a rapidly enlarging ulcerated nodule on the right ankle with a necrotic and crusted center. He also had multiple red-brown papules on the trunk and extremities. Some of these lesions had central erosions, while others had surface scale. He was known to be HIV positive but had no lymphadenopathy.
Diagnosis: Lues maligna is used to describe a rare noduloulcerative form of secondary syphilis.1 It was first described in 18592 and has been associated with other disorders such as diabetes mellitus3 and chronic alcoholism.4 Patients usually are gravely ill and develop polymorphic ulcerating lesions. Facial and scalp involvement are common, but patients typically do not have palmoplantar involvement in conventional presentations of secondary syphilis.
…The patient’s rapid plasma reagin titer at the time of the fourth biopsy was 1:256, and appropriate treatment with penicillin resulted in complete clearance of the lesions in 3 to 4 weeks.
For more information on this case, see “Rapidly Enlarging Noduloulcerative Lesions.” Cutis. 2014;94(3):E20-E22.
Photograph and case description courtesy of Cutis. 2014;94(3):E20-E22.
Related article
Man, 54, With Delusions and Seizures
2011;21(4):20, 22, 24
1. Several weeks ago, this 56-year-old man noticed numerous asymptomatic round macules and papules on his palms and soles, many with scaly peripheral margins. Similar lesions are noted on the penile corona and glans. There is a faint but definite morbiliform, blanchable pink rash covering most of the patient’s trunk, taking on a “shawl” distribution across the shoulders. The patient is exclusively homosexual and recently engaged in high-risk sexual activity.
| |
Diagnosis: It would be hard to imagine a more classic example of secondary syphilis than was seen in this case, occurring in a patient so obviously at risk. But it’s only “obvious” if you’re ready and aware of how syphilis manifests. It also helps if you understand how common it is and who’s likely to get it.
TAKE-HOME LEARNING POINTS
• Palmar and plantar rashes are unusual and should prompt the examiner to expand the history and physical.
• Secondary syphilis, though uncommon, is far from rare, especially among gay men engaging in high-risk sexual behavior.
• It’s common for the patient to deny the appearance of the chancre of primary syphilis, and such a lesion would be long gone by the time those of secondary syphilis manifest.
• Conditions involving the skin should be seen by a dermatology provider, regardless of location. This includes diseases of the skin, hair, nails, oral mucosa, genitals, feet, or palms. One potential exception is the eye itself, though most diseases “of the eye” are, in reality, diseases of the periocular skin—and belong with a dermatology provider.
For more information on this case, see “When There’s More to the Story ….” Clin Rev. 2013;12;2013(12):W2.
For the next photograph, proceed to the next page >>
2. First appearing a month ago, this rash was first confined to the patient’s abdomen and subsequently spread. The blanchable, erythematous papules and nodules are fairly dense, uniformly covering most of his skin but sparing face and soles. Two 7-mm scaly brown nodules are seen on his right palm. There are no palpable nodes in the usual locations. More than 10 years ago, the patient was diagnosed with HIV, which is well controlled with medication. Homosexually active, he denies having any new contacts.
Diagnosis: This case presents a fairly typical clinical picture of secondary syphilis—a diagnosis that requires confirmation with syphilis serology: rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) testing. The latter measures antibodies to the lipids formed by the host against lipids formed on the treponemal cell surface.
In this case, the diagnosis had to be confirmed by more specific treponemal tests, usually conducted by the local health department, to which positive results must be reported. If further testing confirms the diagnosis (as expected), the patient will be treated by the health department. Investigators will question him, attempting to determine the source of the infection and thereby quell an outbreak.
For more information on this case, see “Unusual Cause for Asymptomatic Rash.” Clin Rev. 2013;23(9):W6.
For the next photograph, proceed to the next page >>
3. A 43-year-old man presented with a rapidly enlarging ulcerated nodule on the right ankle with a necrotic and crusted center. He also had multiple red-brown papules on the trunk and extremities. Some of these lesions had central erosions, while others had surface scale. He was known to be HIV positive but had no lymphadenopathy.
Diagnosis: Lues maligna is used to describe a rare noduloulcerative form of secondary syphilis.1 It was first described in 18592 and has been associated with other disorders such as diabetes mellitus3 and chronic alcoholism.4 Patients usually are gravely ill and develop polymorphic ulcerating lesions. Facial and scalp involvement are common, but patients typically do not have palmoplantar involvement in conventional presentations of secondary syphilis.
…The patient’s rapid plasma reagin titer at the time of the fourth biopsy was 1:256, and appropriate treatment with penicillin resulted in complete clearance of the lesions in 3 to 4 weeks.
For more information on this case, see “Rapidly Enlarging Noduloulcerative Lesions.” Cutis. 2014;94(3):E20-E22.
Photograph and case description courtesy of Cutis. 2014;94(3):E20-E22.
Related article
Man, 54, With Delusions and Seizures
2011;21(4):20, 22, 24
1. Several weeks ago, this 56-year-old man noticed numerous asymptomatic round macules and papules on his palms and soles, many with scaly peripheral margins. Similar lesions are noted on the penile corona and glans. There is a faint but definite morbiliform, blanchable pink rash covering most of the patient’s trunk, taking on a “shawl” distribution across the shoulders. The patient is exclusively homosexual and recently engaged in high-risk sexual activity.
| |
Diagnosis: It would be hard to imagine a more classic example of secondary syphilis than was seen in this case, occurring in a patient so obviously at risk. But it’s only “obvious” if you’re ready and aware of how syphilis manifests. It also helps if you understand how common it is and who’s likely to get it.
TAKE-HOME LEARNING POINTS
• Palmar and plantar rashes are unusual and should prompt the examiner to expand the history and physical.
• Secondary syphilis, though uncommon, is far from rare, especially among gay men engaging in high-risk sexual behavior.
• It’s common for the patient to deny the appearance of the chancre of primary syphilis, and such a lesion would be long gone by the time those of secondary syphilis manifest.
• Conditions involving the skin should be seen by a dermatology provider, regardless of location. This includes diseases of the skin, hair, nails, oral mucosa, genitals, feet, or palms. One potential exception is the eye itself, though most diseases “of the eye” are, in reality, diseases of the periocular skin—and belong with a dermatology provider.
For more information on this case, see “When There’s More to the Story ….” Clin Rev. 2013;12;2013(12):W2.
For the next photograph, proceed to the next page >>
2. First appearing a month ago, this rash was first confined to the patient’s abdomen and subsequently spread. The blanchable, erythematous papules and nodules are fairly dense, uniformly covering most of his skin but sparing face and soles. Two 7-mm scaly brown nodules are seen on his right palm. There are no palpable nodes in the usual locations. More than 10 years ago, the patient was diagnosed with HIV, which is well controlled with medication. Homosexually active, he denies having any new contacts.
Diagnosis: This case presents a fairly typical clinical picture of secondary syphilis—a diagnosis that requires confirmation with syphilis serology: rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) testing. The latter measures antibodies to the lipids formed by the host against lipids formed on the treponemal cell surface.
In this case, the diagnosis had to be confirmed by more specific treponemal tests, usually conducted by the local health department, to which positive results must be reported. If further testing confirms the diagnosis (as expected), the patient will be treated by the health department. Investigators will question him, attempting to determine the source of the infection and thereby quell an outbreak.
For more information on this case, see “Unusual Cause for Asymptomatic Rash.” Clin Rev. 2013;23(9):W6.
For the next photograph, proceed to the next page >>
3. A 43-year-old man presented with a rapidly enlarging ulcerated nodule on the right ankle with a necrotic and crusted center. He also had multiple red-brown papules on the trunk and extremities. Some of these lesions had central erosions, while others had surface scale. He was known to be HIV positive but had no lymphadenopathy.
Diagnosis: Lues maligna is used to describe a rare noduloulcerative form of secondary syphilis.1 It was first described in 18592 and has been associated with other disorders such as diabetes mellitus3 and chronic alcoholism.4 Patients usually are gravely ill and develop polymorphic ulcerating lesions. Facial and scalp involvement are common, but patients typically do not have palmoplantar involvement in conventional presentations of secondary syphilis.
…The patient’s rapid plasma reagin titer at the time of the fourth biopsy was 1:256, and appropriate treatment with penicillin resulted in complete clearance of the lesions in 3 to 4 weeks.
For more information on this case, see “Rapidly Enlarging Noduloulcerative Lesions.” Cutis. 2014;94(3):E20-E22.
Photograph and case description courtesy of Cutis. 2014;94(3):E20-E22.
Related article
Man, 54, With Delusions and Seizures
2011;21(4):20, 22, 24