History
A 32-year-old actor presents to the accident and emergency department with a 7-day history of malaise, fever, aching in his joints and neck, and a persistent headache. He has also noticed a rash on his palms and soles and is worried that he might have developed meningitis. He had eczema as a child but otherwise no previous skin problems. He takes antihistamines for hay fever. He lives alone and has no significant past medical history. The casualty officer arranges for some preliminary blood tests and asks for a dermatologi-cal opinion on the skin eruption.
Examination
There are multiple, small erythematous macules 1–4 mm in diameter and patches with mild superficial scale on his palms (Fig. 73.1) and plantar aspect of his feet (Fig. 73.2). Some of the lesions are slightly pigmented and there is some desquamation in places. He has a few similar lesions scattered over his trunk. The lesions are blanching. His mucous membranes, scalp and nails are normal. He has mild neck stiffness but no photophobia and his temperature is 38.0 oC.
Questions
• What is the clinical diagnosis?
• What tests would you need to perform to confirm the diagnosis?
• How would you manage this patient?
Medicine
Fever, headache and a rash is a common combination of symptoms with a wide differ-ential diagnosis. Many viral infections such as measles, chickenpox, Epstein–Barr virus and viral meningitis can present in this way. This patient was concerned about bacte-rial meningitis but the rash was blanching and not purpuric. The diagnosis is secondary syphilis, which can be easily missed. The rash of secondary syphilis is frequently subtle and asymptomatic in most cases. Patients develop non-specific symptoms of malaise and may not present to a medical practitioner.
The rash of secondary syphilis classically affects the palms, soles and trunk, but may become widespread. Lesions start as small erythematous papules and macules that may become slightly scaly and form erythematous-to-pigmented patches. The eruption is usu-ally asymptomatic and may be misdiagnosed as guttate psoriasis. Patients usually devel-op ‘flu-like’ or even ‘meningitis-like’ symptoms. The rash of secondary syphilis usually appears 1–3 months following the initial infection. The spirochete Treponema pallidum is usually transmitted by sexual intercourse and at the site of entry a small painless ulcer (chancre) appears on the genitals/mouth. If syphilis remains untreated a tertiary stage affecting several organ systems can develop many years later. Classically, the central nervous system is affected leading to mental disturbance and even dementia, spinal cord involvement leads to sensory neuropathy and autonomic dysfunction of the bladder. Cutaneous manifestations at this late stage include nodules (gummas) which may ulcerate. Early diagnosis is essential to ensure long-term sequelae are avoided and the infection is not passed on. Serological tests are the key to confirming the diagnosis at the secondary syphilis stage. Specific treponemal antibody tests include TPHA (T. pallidum haemagglu-tination) and TPPA (T. pallidum particle agglutination), which can confirm infection with syphilis. However, the exact timing of disease acquisition may only be estimated owing to rising or falling titres of non-specific tests such as VDRL (Venereal Disease Research Laboratory) and RPR (rapid plasma regain). The latter usually becomes negative after effective treatment whereas TPHA remains positive for life.
If patients present with a chancre, then a smear can be taken onto a glass slide for dark-field immunofluorescence microscopy to identify the spirochaetes. Patients should also undergo a full sexual health screen and be offered an HIV test, as the two diseases may be transmitted simultaneously.Treatment of early disease is with intramuscular benzathine penicillin G 2.4 million units in a single dose, and for late disease is four times weekly for 3 weeks. Use of ceftriaxone and azithromycin is currently being evaluated but appears highly effective. For penicillin-sensitive patients doxycycline has been traditionally prescribed 100 mg daily for 14 days (increased to 30 days in late disease and 200 mg daily for 30 days for neurosyphilis).
KEY POINTS
• The incidence of syphilis worldwide is increasing and may be simultaneously transmitted with HIV.
• The rash of secondary syphilis may be subtle with palmar/plantar red/brown scaly macules/patches.
• A combination of serological tests is usually needed to confirm the disease and the stage.
need an explanation for this answer? contact us directly to get an explanation for this answer