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A 16-year-old male complains of a rash on both hands and feet. The problem began about 3 months earlier with a generalized maculopapular eruption not associated with any other complaints, which lasted about 4 weeks. The generalized rash was evaluated by his primary and was thought to be hives due to exposure to cats; he was prescribed oral Benadryl and topical hydrocortisone 1% cream to be applied to the areas of the skin with the rash. However, the rash on his palms and soles failed to respond to this therapeutic trial. The generalized rash faded, except on the palms and soles where the lesions persisted and became a bit darker.
James H. Brien
Ahdi Amer
His past medical history is that of a previously healthy, sexually active adolescent male, with no prior skin problems. He denies any history of sexually transmitted infections, and his immunizations are documented to be up to date. He has had no known sick contacts, but does attend school where there are classmates with common minor illnesses. He has had no travel or significant insect exposure; he certainly has not had any ticks to pull off. The only animal exposure was to his cat. He has been on no medications prior to the onset of the rash, and no other medications during this 3-month period of time.
Examination reveals normal vital signs and a completely normal exam, except for the dark spots on his palms and soles (Figures 1 and 2). No lab tests are back yet.
Examination reveals normal vital signs and a completely normal exam, except for the dark spots on his palms and soles (Figures 1 and 2).
Source: Brien JH
What’s Your Diagnosis?
A. Drug eruption
B. Pityriasis rosea
C. Secondary syphilis
D. Psoriasis
Case Discussion
The patient had secondary syphilis (C). On further questioning, he revealed that he had been sexually active since age 14 and had sexual intercourse with at least three female partners prior to developing the rash. He does not recall developing genital bumps, ulcerations or any other suspicious lesions.
His serum rapid plasma reagin (RPR) syphilis test was positive at 1:64, and syphilis “treponemal” test was positive. All other tests, including serum HIV-1 and -2 antibody, gonorrhea and chlamydia DNA amplification in urine, were negative. The patient received a single dose of 2.4 million units of benzathine penicillin IM per Red Book Guidelines, and he was asked to return in 6 months for reevaluation and follow-up RPR test. The patient was counseled regarding the risk for syphilis infection and the risk for acquiring other sexually transmitted diseases, including HIV.
Syphilis is an ancient sexually transmitted infection (venereal disease) that is on the rise and is caused by the spirochete Treponema pallidum (subspecies pallidum). The infection is usually transmitted through sexual contact, as T. pallidum rapidly penetrates intact mucous membranes or microscopic dermal abrasions and, within a few hours, enters the lymphatic system and blood to produce systemic infection. Other modes of transmissions can occur, either vertically from mother to fetus in utero, leading to congenital syphilis, or through blood product transfusion. Less commonly, transmission can occur through skin breaks when they come into contact with infectious lesions. The average incubation period from exposure to development of primary lesions is about 3 weeks, but can range from 10 to 90 days before a painless papule appears at the site of inoculation, that usually leads to regional adenopathy.
The initial primary lesion, a painless chancre (Figure 3), may pass unnoticed by the patient. Drug eruptions include a large category of cutaneous conditions, including urticaria (Figure 4).
If the primary infection is unnoticed and left untreated, it can progress through additional stages: secondary, latent and tertiary. The initial primary lesion, a painless chancre (Figure 3), may pass unnoticed by the patient. If so, it may take 3 to 6 weeks to resolve without treatment.
The secondary stage usually develops within 4 to 10 weeks following the appearance of the chancre. It presents with a nonspecific, nonpruritic cutaneous maculopapular eruption that involves the entire body and is usually bilaterally symmetrical. The rash also may involve the palms, soles (as in this patient) and oral mucosa. Each lesion is usually macular, discrete, reddish brown, and about 5 mm in diameter. On the other hand, these lesions can be pustular, annular or scaling, especially in babies. Other manifestations include mild constitutional symptoms of low-grade fever, headache, malaise and generalized adenopathy. Usually during the secondary stage, the immune response is at its peak with high antibody titers detected. Several studies have shown that the central nervous system becomes involved early in the course of the secondary stage, and about 30% of patients have abnormal findings in the cerebrospinal fluid (CSF).
The differential diagnosis for cutaneous manifestation of secondary syphilis might include common viral exanthemas, pityriasis rosea, drug eruptions and psoriasis. However, the appearance of pityriasis rosea starts with a “herald patch,” and the rash appears in a fern-like pattern on the trunk, without involvement of the palms and soles. Drug eruptions include a large category of cutaneous conditions, including urticaria (Figure 4) and erythema multiforme (Figure 5), but implies that the patient is either on, or has recently been on, a medication. This is usually ruled out with history. Psoriasis is a chronic auto-immune skin disorder that may include lesions of the palms, but will have an inflammatory or scaling appearance. The rash of secondary syphilis in this patient was about to resolve spontaneously and pass untreated, as the generalized presence of the lesions particularly on the abdomen and trunk have disappeared. The patient was not aware of the nature of the rash and waited 3 months before seeking medical attention, believing it was due to an allergic reaction.
Drug eruptions include a large category of cutaneous conditions, including erythema multiforme (Figure 5).
The incidence of syphilis has increased dramatically in recent years worldwide, as well as in the United States, especially in urban areas. CDC estimates that there are 55,400 new syphilis infections annually in the US, with an increase in the number of reported cases of syphilis in the last 5 years, particularly among men having sex with men. Clinicians should have a heightened degree of suspicion and be aware of the increased possibility of this infection in general, and within the HIV populations in particular.
I would like to thank Dr. Ahdi Amer for contributing to this case, which raises awareness of this re-emerging, ancient infectious disease. Amer worked on this case with the consulting assistance of Basim Asmar, MD, who is professor of pediatric infectious diseases at the same institution.
For more information:
Ahdi Amer, MD, is an associate professor of pediatrics and associate professor at The Carman and Ann Adams Department of Pediatrics, Wayne State University School of Medicine, Children’s Hospital of Michigan. He has expertise in the field of general academic pediatrics and pediatric infectious diseases. His main areas of interest are vaccine development, vaccine safety and various pediatric dermatologic disorders. He has consulted for UNICEF and WHO on the issue of diarrheal diseases and presented in several international settings on infectious diseases and immunization topics.
James H. Brien, DO, is with the department of infectious diseases at McLane Children’s Hospital, Baylor Scott & White Health, Texas A&M College of Medicine in Temple, Texas. He is also a member of the Infectious Diseases in Children Editorial Board. Brien can be reached at: jhbrien@aol.com.
Disclosure: Amer has conducted clinical research supported by WHO, Merck and Pfizer regarding vaccines and other topics related to infectious and dermatological diseases in children. Brien reports no relevant financial disclosures.