Secondary syphilis - Anogenital in
Secondary syphilis can present with varied manifestations. Patients generally develop constitutional symptoms including malaise, appetite loss, fever, headache, stiff neck, myalgias, pharyngitis, and flu-like symptoms. Generalized lymphadenopathy is typically present. Cutaneous manifestations of secondary syphilis may include a generalized rash that includes the palms and soles. Patchy alopecia or telogen effluvium can be present. Ocular symptoms may include lacrimation, photophobia, and red, painful eyes.
The second stage of syphilis is manifested in the genital area with moist, hypertrophic, papular lesions known as condylomata lata. These lesions can be hyperplastic or verrucous and often look like condylomata acuminata. Condyloma lata can occur adjacent to the site of the primary chancre, especially in immunocompromised individuals. They are teeming with spirochetes and are, therefore, extremely infectious. Uncommonly in the genital area, there can be mucous patches, which are nonspecific, superficial erosions. There may be multiple anogenital lesions, and they may be painful.
The lesions of secondary syphilis resolve in 3-12 weeks, with or without treatment. If left untreated, up to 25% of patients will relapse within the first 2 years.
Per the US Centers for Disease Control and Prevention (CDC), the majority of reported male primary and secondary syphilis cases where sex of sex partner is known are among men who have sex with men. An increased incidence of syphilis is associated with HIV positivity.
Immunocompromised patient considerations: HIV infection can alter the clinical presentation of syphilis. Manifestations include multiple chancres, atypical cutaneous eruptions, increased severity of organ involvement (such as hepatitis and glomerulonephritis), and rapidly developing arteritis and neurosyphilis. Neurosyphilis can occur at any stage of syphilis.
Related topics: primary syphilis, tertiary syphilis, early congenital syphilis, late congenital syphilis, ocular syphilis
A51.39 – Other secondary syphilis of skin
240557004 – Secondary syphilis
- 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.
- Reactive arthritis (Reiter syndrome)
- Tinea corporis – Check potassium hydroxide (KOH) test.
- Scabies – Check for scabies mites in mineral oil.
- Mycosis fungoides
- Granuloma annulare
- Subacute cutaneous lupus erythematosus