A 42-year-old man comes to the office due to a week of subjective fever, sore throat, malaise, headache, and skin rash. The rash began on his trunk a week ago and has now spread to his entire body. He has had no chest pain, shortness of breath, diarrhea, or urethral discharge. The patient was diagnosed with hypertension 2 months ago and started on lisinopril. He has had 3 new female sexual partners over the last year. He drinks alcohol occasionally but does not smoke or use illicit drugs. The patient has not participated in any unusual outdoor activities. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, pulse is 78/min, and respirations are 16/min. Examination shows a full-body maculopapular rash without evidence of excoriations. Several raised, grey mucosal patches are seen in the mouth. Cervical, axillary, inguinal, and epitrochlear lymphadenopathy is present. HIV testing is negative. Which of the following is the most likely cause of this patient's current symptoms?
Syphilis manifestations | |
Primary |
|
Secondary |
|
Latent |
|
Tertiary |
|
CNS = central nervous system. | |
Secondary syphilis typically occurs weeks to months after patients are exposed to Treponema pallidum and develop primary syphilis (chancre). Secondary syphilis is characterized by systemic symptoms (fever, malaise, sore throat, headache), widespread lymphadenopathy (LAD), grey mucous patches, raised grey genital papules (condylomata lata), and a diffuse maculopapular rash that begins on the trunk, extends to the extremities, and involves the palms and soles. The presence of epitrochlear LAD is particularly characteristic of secondary syphilis; it is rumored that sailors would routinely perform a 2-handed "sailor's handshake" (with one hand on the elbow) to determine if potential partners had epitrochlear nodes prior to engaging their company.
Syphilis is diagnosed using a combination of nontreponemal (eg, rapid plasma reagin) and treponemal-specific (eg, T pallidum enzyme immunoassay) serologic tests. Treatment for secondary syphilis is the same as for primary syphilis—one dose of intramuscular penicillin G benzathine—which provides up to 3 weeks of treatment-dose penicillin. Adequate treatment is confirmed by a 4-fold decrease in serologic titers at 6-12 months.
(Choice A) Bacterial endocarditis often causes nonspecific symptoms and cutaneous findings (eg, petechiae, splinter hemorrhages). A diffuse maculopapular rash and LAD would be uncommon.
(Choice B) Drug reactions may cause maculopapular rash but not sore throat or grey mucous patches.
(Choice C) Epstein-Barr virus (EBV) causes sore throat, fever, fatigue, and LAD (infectious mononucleosis). Maculopapular rash may occur but is uncommon. Grey mucous patches are not a common feature of adult EBV infection.
(Choice D) Disseminated gonococcus presents with tenosynovitis, polyarthralgia, and a skin rash that usually consists of a few pustules. This patient has a diffuse rash, LAD, and sore throat, making syphilis far more likely.
(Choice E) Rocky Mountain spotted fever (RMSF) is a tick-borne rickettsial infection marked by high fever, headache, malaise, and a maculopapular rash that usually spreads centripetally toward the trunk (unlike in this patient), includes the palms and soles, and becomes petechial over time. Epidemic typhus is a rare, louse-borne rickettsial infection associated with the abrupt onset of fever, severe headache, and malaise; a centrifugally-spreading macular or maculopapular rash (typically sparing the palms and soles) develops several days later. This patient's grey mucous patches, extensive LAD, multiple new sexual partners, and lack of outdoor exposure make syphilis more likely.
Educational objective:
Secondary syphilis is characterized by systemic symptoms (fever, malaise), widespread lymphadenopathy (particularly epitrochlear), and a diffuse maculopapular rash that begins on the trunk and extends to the extremities, including the palms and soles. Diagnosis is made with serology (using both a treponemal and a nontreponemal test). One intramuscular dose of penicillin G benzathine is the standard treatment.