Case 10 – Q9 Explanation

Review of Answer Choices (Correct Answer in Green): 

• Papulosquamous/maculopapular “copper colored” rash with papules/plaques on palms/soles
• “Moth-eaten” alopecia
• Split papules at the angle of the mouth
• Mucous patches (condyloma lata-like lesions)
• Hypopigmented macules on neck (“necklace of Venus”)
• Condyloma lata

Explanation:

The clinical manifestations of secondary syphilis are extremely varied. Syphilis is “the great mimicker”. There are lots of different cutaneous manifestations of secondary syphilis. Some are pathognomonic and some are less specific. Cutaneous findings can be the only presenting symptoms sometimes. All the answer choices above are associated with secondary syphilis.

• Papulosquamous/maculopapular “copper colored” rash with papules/plaques on palms/soles: This is the characteristic secondary syphilis rash and the palms and soles are involved in 40-80% of cases (see picture below). Palmar and plantar rash should make you think of secondary syphilis, however there are many other infectious skin conditions can involve the palms and soles including erythema multiforme, Rocky Mountain Spotted Fever, Hand-foot-and-mouth disease, etc.

• “Moth-eaten” alopecia: frequency of hair loss in secondary syphilis is 2.9-7%, moth-eaten pattern is the most common type and considered to a pathognomonic manifestation of secondary syphilis; it presents as localized patches of non-scarring alopecia affecting the scalp and sometimes other hair-bearing areas

• Split papules at the angle of the mouth: known as “syphilitic perlèche”, lesions at the angle of the mouth or the corner of the nose which have a central linear erosion
• Mucous patches (condyloma lata-like lesions): painless, shallow, rounded gray, macerated erosions, located on the oral, genital and anal mucosa; these are teeming with treponemes

• Hypopigmented macules on neck (“necklace of Venus”): also called leukoderma syphiliticum or leukoderma colli; they are round or oval, ill-defined, depigmented macules with hyperpigmented borders occurring on the anterolateral neck and chest
• Condyloma lata: skin-colored or hypopigmented, moist, oozing papules located perianally and on the genitalia; they become flattened and macerated; these are teeming with treponemes, and thus are extremely infectious
• (More images: https://vagcel.ru/en/bolezni-pochek-cheloveka/leikoderma-sifiliticheskaya-vidy-leikodermy-sifiliticheskoi.html)

People with secondary syphilis may not have a history of a preceding chancre since the primary infection may have been asymptomatic and/or gone unnoticed. The treatment of choice for secondary syphilis is the same as the primary syphilis. If early syphilis (primary or secondary) is not treated, late syphilis can occur in 25-40% of patients within 1 to 30 years after the primary infection. The clinical manifestations of late syphilis are highly variable, but the most common manifestations include:

• Cardiovascular syphilis (especially aortitis)
• Gummatous syphilis (granulomatous, nodular lesions which are rare, can occur in a variety of organs, usually skin and bones)
• Central nervous system involvement; neurosyphilis can often be seen at the time of secondary syphilis (the treatment for neurosyphilis is benzathine penicillin G 2.4 million units IM weekly x 3 to a total of 7.2 million units)