
Case of secondary syphilis
The clinical image shows the hands of a 41-year-old with symmetric, dusky red and polymorphic papulosquamous rash, diagnosed with secondary syphilis. Examination is generally consistent with regular, round papules identified on palms of the hands, soles of the feet, the trunk and back. The primary chancres of syphilis may go undiagnosed till symptoms of secondary syphilis develop.
The primary infection is traditionally painless and heals within a few weeks
Syphilis, also known as the great imitator is caused by T. pallidum. In the primary infection a traditionally painless, syphilitic chancre is present. The chancre typically heals within a few weeks and for this reason, often goes undetected by the patient. Haematogenous dissemination of T. pallidum occurs up to 6 months after the initial infection, causing secondary syphilis. This prompts the patients to seek medical attention. The dermatological symptoms of secondary syphilis are non-specific and are also often diagnosed by practitioners outside of sexual health. A common manifestation is condylomata lata, which are non-tender and moist papules prevalent in the genital region. They are often also confused with genital warts. 90% of the patients present with a maculopapular rash. The rash is subtle and can easily be confused with pityriasis rosea, a drug reaction, HIV seroconversion and infectious mononucleosis.
One feature that distinguishes the rash from other conditions is the involvement of the palms of the hands and soles of the feet. Mucous patches, although may be subtle, are a hallmark feature of the condition. The lesions are often overlooked unless specifically examined for. If secondary syphilis is left untreated, it may lead to tertiary syphilis. For this reason, it is important for clinicians to do a thorough dermatological assessment of the palms, soles and oral cavity of the patients that present with genital lesions. This is required for making the correct diagnosis.
Source: NEJM