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Secondary syphilis in Child
See also in: Anogenital,Hair and Scalp,Oral Mucosal Lesion
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Secondary syphilis in Child

See also in: Anogenital,Hair and Scalp,Oral Mucosal Lesion
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Contributors: Samantha R. Pop MD, Belinda Tan MD, PhD, Susan Burgin MD
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Synopsis

Syphilis (also known as lues) is a sexually transmitted infection (STI) caused by the spirochete Treponema pallidum. Treponema pallidum is transmitted from person to person through contact with infectious lesions during vaginal, anal, or oral sexual activity, especially when there is disrupted epithelium, such as from minor trauma. Secondary syphilis is the second stage of the infection.

The natural history of syphilis is as follows:

Primary stage:
    • Primary lesion develops 10-90 days (average of 21 days) after direct inoculation.
    • Primary lesion is typically a painless, asymptomatic papule, followed by a painless ulcer (chancre) and regional lymphadenopathy.
    • Chancre lasts 3-6 weeks and heals spontaneously.
    • Locations for chancres may include the vagina, cervix, penis, anus, rectum, lips, and inside of the mouth.
      Secondary stage:
      • Secondary syphilis is caused by hematogenous dissemination of bacteria.
      • A wide range of clinical manifestations, dominated by prodromal symptoms and mucocutaneous manifestations 3-10 weeks after the appearance of the primary chancre.
      • Prodromal symptoms and signs – Malaise, appetite loss, fever, headache, stiff neck, myalgias, pharyngitis, and flu-like symptoms. Generalized lymphadenopathy is typically present.
      • Cutaneous manifestations – Generalized nonpruritic papulosquamous eruption including the palms and soles, with pink, violaceous, or copper-colored papules, each with a collarette of scale. Patchy alopecia of the scalp is also observed in secondary syphilis.
      • Mucosal lesions – Mucous patches and "snail-track" ulcers in the mouth, and condyloma lata (gray, flat, moist papules and plaques) may be seen in moist anogenital locations or, more rarely, in the folds. They are teeming with spirochetes and are, therefore, extremely infectious.
      • Ocular symptoms may include lacrimation, photophobia, and red, painful eyes.
      • 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 and 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.
      Tertiary syphilis:
      • May appear months to years after secondary syphilis resolves and can involve the central nervous system, heart, bones, and skin.
      According to the Centers for Disease Control and Prevention (CDC), primary and secondary syphilis rates have increased in the United States almost every year since 2001. This increase is primarily attributable to an increase among men and particularly among men who have sex with men (MSM). However, since 2013, the rates have increased among both men and women, and the rates of primary and secondary syphilis among women have more than doubled. In 2017, there was a rate of 9.5 cases per 100 000 population in the United States, which represents a 10.5% increase from the year prior and a 72.7% increase compared to 5 years prior.

      Other related topics: Early Congenital Syphilis, Late Congenital Syphilis, Ocular Syphilis

      Codes

      ICD10CM:
      A51.39 – Other secondary syphilis of skin

      SNOMEDCT:
      240557004 – Secondary syphilis

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      Diagnostic Pearls

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      Differential Diagnosis & Pitfalls

      The following differential will be focused on the mucocutaneous findings of secondary syphilis.

      Skin:
      • 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.
      • Lichen planus – Very pruritic, violaceous, scaly papules, associated with hepatitis C; consider tissue biopsy.
      • Lichen amyloidosis – Monomorphous papules.
      • 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 eosinophilia is not an invariable finding). Look for NSAIDs, sulfonamides, and penicillin on 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 (eg, herpes simplex virus, mycoplasma) and usually not medication related.
      • Keratoderma blenorrhagica of reactive arthritis (Reiter syndrome)
      • Tinea corporis – Check potassium hydroxide (KOH) test.
      • Scabies – Check for scabies mites in mineral oil.
      • Sarcoidosis
      • Subacute cutaneous lupus erythematosus
      Oral ulcers:
      Patchy alopecia:

      Best Tests

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      Therapy

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      References

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      Last Reviewed: 02/22/2019
      Last Updated: 03/05/2019
      Copyright © 2019 VisualDx®. All rights reserved.
      Secondary syphilis in Child
      See also in: Anogenital,Hair and Scalp,Oral Mucosal Lesion
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      Secondary syphilis : Fever, Headache, Rash, Lymphadenopathy, Malaise, Oral white plaque, Widespread, Anorexia, Arthralgia, Multiple sexual partners, Myalgia, Pharyngitis, Stiff neck, Scaly papules
      Clinical image of Secondary syphilis
      Multiple brown papules and small plaques, some with overlying thick scales and others with collarettes, on the palm.
      Copyright © 2019 VisualDx®. All rights reserved.