Secondary syphilis in Adult
Secondary syphilis usually presents with a generalized rash that includes the palms and soles. Condyloma lata may be seen in moist anogenital locations or in the mouth. They are teeming with spirochetes and are, therefore, extremely infectious. Symptoms may include malaise, appetite loss, fever, headache, stiff neck, myalgias, lacrimation, photophobia, red and painful eyes, back pain, arthralgias, pharyngitis, flu-like symptoms, pruritus (more common in immunocompromised patients), lymphadenopathy, splenomegaly, bursitis, and tenosynovitis. In late stages, blindness and epigastric pain may occur.
The lesions of secondary syphilis heal in 2-10 weeks, with or without treatment. If left untreated, up to 25% of patients will relapse within the first 2 years.
Ocular screening (eg, slit lamp examination) is advised for patients with suspected or proven syphilis.
The natural history of syphilis is as follows.
- Primary lesion develops 10-90 days (average of 3 weeks) after direct inoculation.
- Primary lesion is a painless, asymptomatic papule, followed by ulceration (chancre) and regional lymphadenopathy.
- Chancre lasts 3-6 weeks and heals spontaneously.
- All patients with primary syphilis will go on to develop secondary syphilis if left untreated.
- Characterized by hematogenous and lymphatic dissemination.
- Wide range of clinical manifestations but dominated by mucocutaneous and prodromal symptoms 3-10 weeks after appearance of primary chancre.
- Cutaneous manifestations – Generalized nonpruritic papulosquamous eruption including the palms and soles, with pink to violaceous, scaly papules. Patchy alopecia of the scalp is also observed in secondary syphilis.
- Mucosal lesions – Ulcers, gray-colored plaques, and condyloma lata.
- Prodromal symptoms – Fever, weight loss, malaise, lymphadenopathy, myalgias, and sore throat.
- Malignant syphilis (lues maligna) is a rare noduloulcerative manifestation of secondary syphilis. A generalized eruption of papules and nodules progresses to pustules and then to ulcers with overlying thick or rupioid (darkly colored conical) crusts. Constitutional symptoms and generalized lymphadenopathy are usually seen. Most contemporary cases of malignant syphilis have been reported in the setting of underlying human immunodeficiency virus (HIV) infection.
- Mucocutaneous manifestations and prodromal symptoms last 3-12 weeks and resolve spontaneously.
- If left untreated, up to 25% of patients will relapse within the first 2 years.
- May appear months to years after secondary syphilis resolves and can involve the central nervous system, heart, bones, and skin.
Other related topics: Early Congenital Syphilis, Late Congenital Syphilis, Ocular Syphilis
A51.39 – Other secondary syphilis of skin
240557004 – Secondary syphilis
- Lichen planus – Very pruritic, associated with hepatitis C, violaceous, scaly papules; consider tissue biopsy.
- Lichen amyloidosis – Monomorphous papules.
- Pityriasis rosea – Look for herald patch, collarette of scale, and orientation of lesions (fir-tree pattern in skin tension lines).
- Pityriasis rubra pilaris – Look for orange-red, waxy-like keratoderma of the palms and soles; consider tissue biopsy.
- Guttate psoriasis – Systemic signs absent, palms and soles are spared; biopsy will aid in diagnosis.
- Drug eruption – Cutaneous lesions of drug eruption tend to be different than those seen in syphilis. Drug eruptions often present with urticarial, exanthematous, or vesicular / bullous lesions. Eosinophilia on CBC and histology are often seen (but not an invariable finding). Look for nonsteroidal anti-inflammatory drugs, sulfonamides, and penicillin medication history.
- Erythema multiforme – Characteristic target lesions (3 concentric colors that are round and well-demarcated) occur on the extremities more often than the trunk. Precipitating factors are infectious (herpes simplex virus, mycoplasma, etc) and usually not medication related.
- Reactive arthritis (Reiter syndrome)
- Tinea corporis – Check KOH.
- Scabies – Check for scabies mite in mineral oil.
- Subacute cutaneous lupus erythematosus