SECONDARY SYPHILIS-BLAST FROM THE PAST
P. Manasa Veena1, M. Arun Kumar2, P. Vidyasagar3, Ch. Vijay Bhaskar Reddy4
1Post Graduate, 2Professor & Head, 3Associate Professor ,4Senior Resident, Department of Dermatology,Venereology and Leprosy, Kamineni Institute of Medical Sciences, Narketpally.
Syphilis has a myriad of presentations and can mimic many diseases- “The great impostor.” The complex and variable manifestations of the disease prompted Sir Osler to remark “The physician who knows syphilis knows medicine”1. It is caused by Treponema pallidum, is acquired through sexual intercourse or vertical transmission. It is classified as primary, secondary and tertiary syphilis.
A 25 year old female patient presented with asymptomatic, multiple, dark coloured, and slightly raised pea sized lesions on both palms and soles and multiple pale lesions all over the body since one month. Patient had a single episode of low grade, continuous fever which subsided on taking medication. Then she observed multiple, dark coloured, raised lesions on both palms and soles. Simultaneously she also observed multiple, pale, lesions on face and extremities. No history of trauma, seasonal exacerbations, joint pains, burning micturition, diarrhea, genital lesions before the onset of skin lesions. Patient denied premarital or extramarital sexual exposure. Patient alleged that her husband had multiple sexual partners, currently patient was separated from the spouse.
Figure 1a: Clinical photograph showing multiple, polysized, hyperpigmented, discrete as well as coalescing, annular, scaly plaques involving both the palms.
Cutaneous examination showed multiple, polysized (with largest measuring 2cm x 1.5 cm and smallest measuring 0.5cm x 0.5cm), annular, scaly, hyperpigmented plaques on both palms and soles and multiple, polysized, symmetrical,
Figure 1b: Clinical photograph showing polysized, hyperpigmented, discrete as well as coalescing , annular, scaly plaques involving both the soles.
Figure 2a (10x): Histopathology (H&E stain) showing orthokeratosis with hypergranulosis, acanthosis, mild downward elongation of rete ridges.
hypopigmented macules all over the body. No evidence of hair loss, mucous membrane lesions. Bilateral, nontender inguinal lymphadenopathy noticed. Systemic examination was unremarkable. Based on history and cutaneous examination, a provisional diagnosis of Secondary syphilis was considered and subjected to necessary investigations to rule out other differential diagnosis like palmoplantar psoriasis, Reiters syndrome, photosensitive drug rash.
Figure 2 b(40x):Papillary dermis shows dilated bloodvessels with plump endothelial cells which are seen surrounded by lymphocytes, histiocytes and occasional plasma cells.
Blood investigations showed Hb-10gm%, Rapid plasma reagin (RPR) test was reactive in 1:64 dilution, Treponema Pallidum Haemagglutination Assay was positive (2680 OD Ratio). HIV was non- reactive. Biopsy section showed orthokeratosis with hypergranulosis. Acanthosis mild downward elongation of rete ridges. Papillary dermis shows dilated blood vessels with plump endothelial cells which are seen surrounded by lymphocytes, histiocytes and occasional plasma cells. Patient was treated with Benjathine Penicillin according to NACO guidelines. Inj Benzathine Penicillin i.e., 0.5ml given on flexor aspect of left forearm intradermally. Inj Benzathine Penicillin (50,000mIU/kg) deep IM -1.75mIU (B.wt- 35kgs), 1.2 MU on one buttock and 0.55MU on other buttock after test dose. Oral haematinics were supplemented. In 6 weeks follow up, patient showed clinical improvement as well as fall in RPR titer to 1:32. Patient didn’t turn up for further follow up.
Figure 3 a & b: Regression of plaques to hyperpigmented macules on palms and soles respectively after treatment on six weeks of follow up.
Figure 4 a & b:Pictures showing fall in titres of Rapid plasma regain test values before and after treatment on six weeks of follow up
Secondary syphilis should be considered as a good imitator in view of its protean clinical and laboratory presentations, which not uncommonly mimic other diseases.1 The appellation of syphilis as "the great imitator" has been attributed to Sir William Osler, but in reality was coined by Sir Jonathan Hutchinson almost 20 years earlier.2 The eruption of secondary syphilis has certain characteristics that help to identify and distinguish it from other dermatoses. The cutaneous manifestations characterizing secondary syphilis are usually superficial, classically comprising major types of rash: macular, papular, annular, papulosquamous or pustular.3 Nodular lesions in syphilis are typical of the late benign stage of the disease. The eruption is generalized, involving both skin and mucous membranes, is bilateral, symmetrical and more prominent on the upper extremities than on the abdomen and the lower
extremities. It has a special predilection for the palms and the soles although these may be clear only in the early stages. The lesions are discrete rather than confluent, have a coppery hue and are sharply demarcated. Scales when present tend to be located peripherally rather than centrally. Although many patients with secondary syphilis do not show systemic symptoms, a variety of complaints and lesions suggests systemic infection. Unproven, but probable, is that most of this population goes on to exhibit tertiary disease. The systemic symptoms and lesions are usually not distinctive; they can include sore throat, malaise, headache, fever, weight loss, nausea, arthrititis, periostitis, myalgia, hepatitis, nephritis and various neurologic signs and symptoms.4 The generalized nature of these signs and symptoms reflects the constitutional effects of systemic inflammation. The localized symptoms most likely indicate focal inflammation in the internal organs affected, whose pathologic findings resemble the cutaneous lesions of secondary syphilis, i.e., delayed type hypersensitivity reactions to organisms that are present at a local site within the tissue.
Syphilis has had a worldwide resurgence in HIV era and remains a challenging public health problem. It can be treated easily if recognized early. The challenge lies in recognizing important diagnostic clues, including the characteristic skin rashes and mucosal lesions. Our patient reported with skin lesions suggestive of secondary syphilis. However, absence of associated mucous membrane changes made diagnosis slightly difficult. This was further compounded by sero-positivity to RPR test done in higher dilutions. Early diagnosis always helps to prevent late sequelae of the disease. Benzathine Penicillin remains gold standard of treatment for early syphilis till date. One should have a clear insight and sound knowledge in diagnosing early cases of syphilis to prevent spread of the disease in the community.
- Jackson R.Jonathan Hutchinson on syphilis.Sex Transm Dis 1980;7:90-6.
- Chapel TA.Primary and secondary syphilis. Cutis 1984;33:47-53.
- Wang Q, Zhang G. Guidelines for Diagnosis and Treatment of Sexually Transmitted Diseases. Sex Transm Dis 2007;12:238-40.
- Brown W, Pierce L. Clinical aspects of cutaneous syphilis. J Exp Med. 1920;32:473–495.