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Secondary Syphilis

Secondary syphilis is the stage of the sexually transmitted disease syphilis in which the patient is most contagious. The main clinical feature is a maculopapular rash that appears on the whole body that extends to the palms and soles, while generalized lymphadenopathy and constitutional symptoms may be present as well. The diagnosis can be made clinically and confirmed by serology. Treatment includes administration of penicillin in a single dose intramuscularly.


Presentation

Secondary syphilis can present with a very broad range of symptoms. However, the hallmark of this stage of infection is the appearance of a maculopapular rash. The diameter of lesions, which are red-to-brown in color, ranges from 3-10 mm and initially appear on the trunk, followed by their dissemination to the extremities, including the palms and soles, which is one of the main distinguishing features [9]. Condylomata lata is a term that describes the development of raised grayish or white papillary skin lesions in intertriginous areas, which are also specific features for secondary syphilis. Macules and papules may progress into pustules. Mucous patches, grayish oval-shaped erosions or ulcerations are also commonly observed in patients during this stage.

Apart from skin lesions, patients may exhibit symptoms related to virtually any organ. Constitutional symptoms, such as fever, malaise, weight loss, myalgia, and arthralgia may precede the rash. Generalized lymphadenopathy, involving cervical, axillary and inguinal regions, is frequently present. Gastrointestinal involvement may result in symptoms such as vomiting, abdominal pain. Ocular involvement, including the development of keratitis, uveitis, retinitis, optic neuritis may occur [10]. Periostitis, meningitis, hepatitis and pharyngitis may also be encountered in variable percentages.

Lues maligna is a rare, but severe presentation of secondary syphilis, which presents with generalized progressive polymorphic ulcers accompanied with the poor systemic condition [4].

Fever
  • Abstract A 34-year-old, HIV-positive man living in Texas presented with a 2-week history of fever, malaise, myalgias, oral ulcers, and papules on his chest, back, face, and extremities, including the palms.[ncbi.nlm.nih.gov]
  • Secondary syphilis is characterized by systemic symptoms, such as malaise and fever as well as a maculopapular rash involving the trunk and extremities including the palms and soles.[ncbi.nlm.nih.gov]
  • A 30-year-old male presented with history of fever and cough of one month duration. He was seropositive for human immunodeficiency virus infection one year back. He had discrete multiple papular and papulonodular patches all over the body.[ncbi.nlm.nih.gov]
  • A 56-year-old man developed disseminate lymphadenopathies, associated with hepato-splenomegaly, fever, nocturnal sweating and weight loss. Imaging studies in particular FDG-PET/CT raised the suspicion of a malignant disease.[ncbi.nlm.nih.gov]
  • A 21-year-old Brazilian man presented with a two-month history of asymptomatic cutaneous lesions accompanied by fever and fatigue.[ncbi.nlm.nih.gov]
Malaise
  • We report a case in which an HIV-positive man developed general malaise, skin rash and biochemical hepatitis within days of starting a nevirapine-based antiretroviral treatment regimen. At the same time, his syphilis serology proved positive.[ncbi.nlm.nih.gov]
  • Abstract A 34-year-old, HIV-positive man living in Texas presented with a 2-week history of fever, malaise, myalgias, oral ulcers, and papules on his chest, back, face, and extremities, including the palms.[ncbi.nlm.nih.gov]
  • Secondary syphilis is characterized by systemic symptoms, such as malaise and fever as well as a maculopapular rash involving the trunk and extremities including the palms and soles.[ncbi.nlm.nih.gov]
  • This response is characterized by low-grade fever, myalgias, headache and malaise that begin within a few hours after initiation of therapy and last for 12–24 h.[cmaj.ca]
Fatigue
  • A 50-year-old man with general fatigue and weight loss underwent FDG PET/CT scan to detect possible occult malignancy. The images revealed abnormal FDG activity in the tonsils, right lung, and in the cervical, axillary, and inguinal lymph nodes.[ncbi.nlm.nih.gov]
  • A 21-year-old Brazilian man presented with a two-month history of asymptomatic cutaneous lesions accompanied by fever and fatigue.[ncbi.nlm.nih.gov]
  • In addition to the rash, other symptoms of secondary syphilis include: Fever Sore throat Headache Swollen lymph glands and nodes Fatigue Muscle aches and joint pain Weight loss and loss of appetite Hair loss Patches near genitals or skin folds that resemble[medguidance.com]
  • Other symptoms of secondary syphilis include: sore throat fever swollen lymph glands headaches fatigue muscle aches wart-like patches around skin folds or genitals loss of appetite joint pain enlarged lymph nodes To diagnose secondary syphilis, your doctor[healthline.com]
Chills
  • Photo Credit Dolly Faibyshev for The New York Times Work Out and Chill? Cool temperature workouts may be the answer for those who want to exercise without becoming a hot mess.[nytimes.com]
  • After you have received the treatment, you may suffer from a reaction known as Garish-Herxheimer, during which you may have nausea, aches and pains, headache, fever and chills. Usually, these symptoms only last one day.[medguidance.com]
  • Symptoms of Jarisch-Herxheimer include: chills rash fever of up to 104 degrees Fahrenheit tachycardia ( rapid heart rate ) hyperventilation headache muscle aches joint pain nausea The Jarisch-Herxheimer reaction is common and potentially serious.[healthline.com]
  • Symptoms and signs of this reaction include: Chills Fever General ill feeling ( malaise ) Headache Muscle and joint pain Nausea Rash These symptoms usually disappear within 24 hours.[medlineplus.gov]
Prostitute
  • The patient reported sexual contact with a prostitute 8 weeks previously and a penile lesion 6 weeks earlier. Physical examination revealed an erythematous papular rash on the trunk.[ncbi.nlm.nih.gov]
  • ‘He never married, and it is possible that as a young man he contracted syphilis during a single sexual encounter with a prostitute.’ ‘There was also an increase in other sexually transmitted diseases, such as syphilis and chlamydia.’[oxforddictionaries.com]
  • The child's 60-year-old maternal grandfather admitted to having unprotected sex with a prostitute about 4 months prior while still having sex with his 55-year-old wife who acted as the girl's caregiver.[journals.lww.com]
Generalized Lymphadenopathy
  • Generalized lymphadenopathy could be an indication of various diseases including malignancies or infections.[ncbi.nlm.nih.gov]
  • He also presented with an associated erythematous maculo-papular rash on the trunk and limbs and generalized lymphadenopathy (Figure 2, a, b). The tibial crest and radius were sensitive to palpation.[ncbi.nlm.nih.gov]
  • Generalized lymphadenopathy, involving cervical, axillary and inguinal regions, is frequently present. Gastrointestinal involvement may result in symptoms such as vomiting, abdominal pain.[symptoma.com]
  • Signs Highly infectious lesions can occur on mucus membrane Generalized Lymphadenopathy Papulosquamous Dermatosis Characteristics Pale, pink to red discrete round Macula r to papular lesions Scaling over surface Size: "Nickels and Dimes" Papule s Plaque[fpnotebook.com]
Splenomegaly
  • A 56-year-old man developed disseminate lymphadenopathies, associated with hepato-splenomegaly, fever, nocturnal sweating and weight loss. Imaging studies in particular FDG-PET/CT raised the suspicion of a malignant disease.[ncbi.nlm.nih.gov]
  • […] leukoderma ( ICD-10-CM Diagnosis Code A52.79 Other symptomatic late syphilis 2016 2017 2018 2019 Billable/Specific Code Applicable To Late syphilitic leukoderma Syphilis of adrenal gland Syphilis of pituitary gland Syphilis of thyroid gland Syphilitic splenomegaly[icd10data.com]
  • Less common symptoms of secondary syphilis include: Weight loss Patchy alopecia (hair loss) Kidney problems (such as glomerulonephritis) Meningitis Hepatitis Splenomegaly (an enlarged spleen) Cranial nerve palsies (weakness or paralysis of nerves in the[ada.com]
  • Less common presentations include patchy alopecia, anterior uveitis, meningitis, cranial nerve palsies, hepatitis, splenomegaly, periostitis and glomerulonephritis.[patient.info]
Rectal Pain
  • A 37-year-old white man with HIV who was receiving highly active antiretroviral therapy presented to the Emergency Department with 6 weeks of rectal pain. He had a CD3-CD4 count of 656 cells/mm3 and an undetectable viral load.[ncbi.nlm.nih.gov]
Aphthous Stomatitis
  • These were wrongly diagnosed as 'aphthous stomatitis' and treated with betamethasone gargling. Perforation of the palate occurs following development fo gumma in late stage of syphilis.[ijdvl.com]
Hepatosplenomegaly
  • Hepatosplenomegaly may be present. In some cases lesions of secondary syphilis appear before the chancre heals.[dartmouth.edu]
  • There was no hepatosplenomegaly. Fig. 1: Papulosquamous lesions on the patient's trunk. Fig. 2: Mucous patches involving the lips. Fig. 3: Involvement of the palm. Blood samples were taken for HIV antibody and VDRL testing.[cmaj.ca]
  • Diagnosis: Early (first two years): rash including condylomata lata, vesiculobullous lesions, snuffles, haemorrhagic rhinitis, osteochondritis, periostitis, pseudoparalysis, mucous patches, perioral fissures, hepatosplenomegaly, generalised lymphadenopathy[patient.info]
Hepatomegaly
  • Physical examination was remarkable only for hepatomegaly. His hematocrit was 36%, ESR 122mm/hr, iron 18, TIBC 204, alkaline phosphatase 199; other liver function studies were normal. CEA, AFP, SPEP and B-HCG levels were normal.[med.harvard.edu]
Arthritis
  • After excluding the aetiologies of cancer metastasis and tuberculosis, we confirmed the diagnosis of syphilitic arthritis. The patient received the medical treatment of antibiotics and the surgical treatment of total hip arthroplasty.[ncbi.nlm.nih.gov]
  • […] semilunar valve 半月弁 seminal vesicle 精嚢 seminiferous tubule 精細管 seminoma セミノーマ/精上皮腫 sensitization 感作/増感 sensory dissociation 知覚解離/感覚解離 sensory-motor period 感覚運動期 separation anxiety disorder 分離不安障害 separation-individuation 分離・個体化 sepsis/septicemia 敗血症 septic arthritis[jpeds.or.jp]
  • Syphilis was once a major public health threat, commonly causing serious long-term health problems such as arthritis, brain damage, and blindness.[webmd.com]
  • Osteomyelitis, septic arthritis and soft tissue infection: the organisms. In: Diagnosis of bone and joint disorders. Philadelphia, Saunders. 1981; Ch. 62. 3) Tight R and Warner J. Skeletal involvement in secondary syphilis detected by bone scanning.[med.harvard.edu]
  • Asymptomatic infants may develop inflammation of the cornea (keratitis), arthritis, deafness, and central nervous system damage later in life.[healthcommunities.com]
Eruptions
  • The most commonly observed cutaneous presentation is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement.[ncbi.nlm.nih.gov]
  • Similarly, the histology of secondary syphilitic lesions may show considerable variation, depending on the clinical morphology of the eruption.[ncbi.nlm.nih.gov]
  • Secondary syphilis has a variety of presentations, the most common being a diffuse symmetrical papulosquamous eruption.[ncbi.nlm.nih.gov]
  • The recent resurgence of syphilis mandates that clinicians maintain a heightened suspicion for Treponema infection, and that they be aware of the variety of cutaneous presentations that may mimic eczema, psoriasis, drug eruption, erythema multiforme,[ncbi.nlm.nih.gov]
  • Abstract The typical finding in secondary syphilis stage is a generalized non-pruritic maculopapular eruption.[ncbi.nlm.nih.gov]
Alopecia
  • ) , Alopecia syphilitic , Syphilitic alopecia , Syphilitic alopecia (disorder) Czech Syfilitická alopecie Hungarian alopecia syphilitica , syphilises alopecia Spanish alopecia sifilítica (trastorno) , alopecia sifilítica , Alopecia sifilítica Portuguese[fpnotebook.com]
  • Alopecia syphilitic, Syphilitic alopecia, Syphilitic alopecia (disorder) Czech Syfilitická alopecie Hungarian alopecia syphilitica, syphilises alopecia Spanish alopecia sifilítica (trastorno), alopecia sifilítica, Alopecia sifilítica Portuguese Alopecia[fpnotebook.com]
  • BACKGROUND: Syphilitic alopecia (SA) is mainly described in single case reports, and there are only a few epidemiological studies.[ncbi.nlm.nih.gov]
  • Alopecia, anogenital condylomata lata and pitted hyperkeratotic palmoplantar papules (syphilis cornee) may also be seen. In severe cases, ulcerative lesions termed lues maligna may develop.[dermpedia.org]
  • Patchy alopecia of the scalp and loss of the lateral eyebrows occur in some patients. Lymphadenopathy, fever, and malaise may also be present. A history of an ulcerating primary lesion (chancre) mayor may not be obtainable.[streetdirectory.com]
Cutaneous Manifestation
  • Abstract Syphilis is a well-known sexually transmitted infection infamous for its protean cutaneous manifestations.[ncbi.nlm.nih.gov]
  • Physicians must be aware of syphilis in daily practice, since the vast spectrum of its cutaneous manifestations is rising worldwide.[ncbi.nlm.nih.gov]
  • Anetoderma in syphilis is rare, and occurs even in the most uncommon cutaneous manifestations of the disease, such as the nodular form.[ncbi.nlm.nih.gov]
  • Nevertheless, reports of renal syphilis with mucosal and/or cutaneous manifestations are nowadays increasing. Typically, secondary syphilis infection in adults causes nephrotic syndrome due to a membranous glomerulonephritis.[ncbi.nlm.nih.gov]
  • Cutaneous manifestations of secondary syphilis are protean and skin tuberculosis may be considered in the differential diagnosis, especially in HIV-infected patients.[ncbi.nlm.nih.gov]
Eczema
  • The recent resurgence of syphilis mandates that clinicians maintain a heightened suspicion for Treponema infection, and that they be aware of the variety of cutaneous presentations that may mimic eczema, psoriasis, drug eruption, erythema multiforme,[ncbi.nlm.nih.gov]
  • The clinical hypothesis was dyshidrotic eczema and Bowen's disease for the finger lesion and nummular eczema for the leg lesion. An incisional biopsy was performed in both lesions.[karger.com]
  • […] commonly, tuberculosis , chancroid Anal ulcers : genital herpes , anal fissure , bacterial infections , trauma, inflammatory bowel disease Mouth ulcers : herpes simplex (cold sore) , aphthous ulcers , trauma Rash Drug eruption Pityriasis rosea Psoriasis Eczema[dermnetnz.org]
  • […] less commonly, tuberculosis, chancroid Anal ulcers : genital herpes, anal fissure, bacterial infections, trauma, inflammatory bowel disease Mouth ulcers : herpes simplex (cold sore), aphthous ulcers, trauma Rash Drug eruption Pityriasis rosea Psoriasis Eczema[dermnetnz.org]
Rash of the Hands and Feet
  • A 39-year-old Japanese man presented to our hospital complaining of left chest pain and rash on the hands and feet. Plain thoracic computed tomography (CT) revealed multiple nodular shadows in the left lower lobe of the lung.[ncbi.nlm.nih.gov]
  • Secondary syphilis (if the infection wasn't treated, usually a month after first contact) - a non-painful rash, especially on hands and feet; feeling generally unwell and tired; swollen glands; joint pains and warty lumps on the genitals.[patient.info]
Headache
  • Patients present with bone pain, which may manifest as headaches or shin splits, depending on the affected bone.[ncbi.nlm.nih.gov]
  • After you have received the treatment, you may suffer from a reaction known as Garish-Herxheimer, during which you may have nausea, aches and pains, headache, fever and chills. Usually, these symptoms only last one day.[medguidance.com]
  • Cutaneous lesions are preceded by a flulike syndrome (sore throat, headache, muscle aches, meningismus, and loss of appetite) and generalized, painless lymphadenopathy. Hepatosplenomegaly may be present.[dartmouth.edu]
  • This response is characterized by low-grade fever, myalgias, headache and malaise that begin within a few hours after initiation of therapy and last for 12–24 h.[cmaj.ca]
  • Symptoms of Jarisch-Herxheimer include: chills rash fever of up to 104 degrees Fahrenheit tachycardia ( rapid heart rate ) hyperventilation headache muscle aches joint pain nausea The Jarisch-Herxheimer reaction is common and potentially serious.[healthline.com]
Syphilitic Chancre
  • Perforation of the syphilitic chancre on the shaft of penis following topical triamcinolone has been reported. [4] Steroids whether topical or systemic are detrimental in infectious diseases such as leprosy and syphilis in the absence of specific antibacterial[ijdvl.com]
  • Discussion In the primary form of the disease, the specific lesion is the syphilitic chancre, which may be associated with a regional, painless, nonsuppurative lymphadenomegaly [ 2 , 8 ].[karger.com]
  • chancre NOS secondary A51.39 atrophoderma maculatum A51.39 Ulcer, ulcerated, ulcerating, ulceration, ulcerative syphilitic (any site) (early) (secondary) A51.39 ICD-10-CM Codes Adjacent To A51.39 A50.6 Late congenital syphilis, latent A50.7 Late congenital[icd10data.com]
  • Syphilis Diagnosis Primary syphilis is diagnosed when the syphilitic chancre on the genitals is observed and by reviewing the patient's sexual history.[healthcommunities.com]

Workup

The initial diagnosis of syphilis in the secondary stage can be made based on properly obtained patient history and thorough physical examination. Recent sexual behavior that may have posed a risk for contracting an STD, together with typical features such as disseminated rash including the palms and soles, condylomata lata, and the recent development of chancres (the hallmark of primary syphilis) can provide key elements in establishing the diagnosis. A confirmation of T. pallidum as the causative agent can be done using various tests [11]:

  • Microscopical evaluation - Because T. pallidum cannot be visualized by classical light microscopy, special methods must be used. Darkfield microscopy is a method which includes an immediate examination of material scraped from skin lesions, which can detect viable spirochetes. However, because T. pallidum cannot survive laboratory transport, the direct fluorescent antibody (DFA) test is more commonly used, which comprises introduction of fluorescent anti-treponemal antibodies into the sampled material. Antibodies bind to spirochetes that are both motile and nonmotile, but more importantly, oral and rectal swabs can be examined by this method since darkfield microscopy may identify commensal spirochetes from these regions and make a falsely positive diagnosis [5].
  • Serology - There are various tests that can be used for confirming syphilis. The serologic evaluation includes non-treponemal tests that confirm the presence of antibodies reacting with certain cellular components that bind to T. pallidum. Treponemal tests, on the other hand, detect T. pallidum-specific antibodies. Non-treponemal tests include Venereal Disease research Laboratory (VDRL) test and the Rapid Plasma Reagin (RPR) test, which are shown to be 100% sensitive in secondary stages of syphilis [5], but certain diseases, such as systemic lupus erythematosus (SLE) or antiphospholipid syndrome may present with positive VDRL and RPR levels. Fluorescent treponemal antibody-absorption (FTA-ABS) and Treponema pallidum particle agglutination (TP-PA) are two treponemal tests which are used in making a definite diagnosis [12]. The first include binding of fluorescent antibodies to T. pallidum, while TP-PA is a test in which agglutination of particles occurs if the inspected material contains T. pallidum antigens.

All patients with suspected syphilis should be tested for HIV infection, as well as hepatitis B and C and other STDs, including Chlamydia trachomatis and Neisseria gonorrhea because their coinfection is not uncommon.

Treatment

The mainstay of treating patients in secondary syphilis, but in other stages as well, is the administration of penicillin. Administration of 2.4 million units as a single dose IM is the recommended regimen [13]. Alternative regimens include administration of ceftriaxone 1g either IM or IV q24h for 10-14 days, azithromycin 2g as a single dose PO, doxycycline 100 mg PO q12h for 14 days, or tetracycline 500 mg PO q6h for 14 days, depending on history of allergies or other factors which limit the use of penicillin, but virtually all regimens except azithromycin has shown inferior results to penicillin [14].

In rare cases, a systemic reaction that occurs 6-8 hours after administration of therapy, known as Jarisch-Herxheimer reaction, may occur and is most commonly observed in patients who are treated in the secondary stage of syphilis [4]. The cause involves the release of various components of treponemes that are being killed by antibiotics and are recognized by cells of the immune system. As a result, massive activation of pro-inflammatory cells and release of cytokines lead to development to either mild or severe and life-threatening symptoms. Fever, headache, hypotension and tachycardia usually appear and resolve within 24 hours, but patients in later stages of syphilis may develop life-threatening complications.

Prognosis

The prognosis of patients with secondary syphilis is very good if treatment is initiated, as complete recovery and cure may occur with timely treatment. However, without treatment, patients may progress into a latent stage and eventually develop tertiary syphilis, with cardiovascular and neurologic complications that can pose a significant risk to the patient. In very rare cases, severe variants of secondary syphilis (known as Lues maligna) may develop [4].

Etiology

Treponema pallidum is a bacterial pathogen belonging to the group of spirochetes because of their coiled and helical shape. It is very thin (0.1-0.5 µm x 5-20 µm), which makes it undetectable under light microscopy. This bacteria thrives under anaerobic or microaerophilic (very low O2 concentrations) conditions, as it is extremely sensitive to oxygen. T. pallidum readily crosses the blood-brain barrier and the placental barrier, because of its potent virulence. It is able to move through tissues by using flagellar ligaments located in the periplasmic space, which extend virtually throughout the entire spirochete [4]. Its unique characteristics include the ability to maximally reduce expression of lipoproteins and other molecules on its outer membrane, which enables it to evade immune defenses and recognition by dendritic cells and macrophages.

Epidemiology

Syphilis is diagnosed in all parts of the world with variable prevalence and incidence rates. Overall, it is estimated that 10.6 million new cases occurred annually in the year 2008, while more than 36.4 million individuals had active syphilis [2]. Incidence rates were highest in Africa, where it is established that syphilis occurred in approximately 8-9 per 1000 individuals, while the European regions reported incidence rates of less than 1 per 1000 [2]. In the United states, Syphilis is established to be the third most common STD, after Chlamydia trachomatis and Neisseria gonorrhea [5]. The main mode of transmission includes any form of sexual contact, but vertical transmission can also occur. More than 1.3 million pregnant women were estimated to have active syphilis worldwide [6], which presents a significant risk for fetal invasion of T. pallidum. A significant predilection toward male gender is established, with a 2-4:1 ratio, perhaps because the highest incidence rates of this STD is noted among men who are having sex with men (MSM population) [7].

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of syphilis invariably starts with the transmission of T. pallidum via direct contact from the infected host, primarily during sexual intercourse and its inoculation to the skin or mucosa. Once the bacteria reaches the new host, it is able to penetrate through the initial layers of the skin through breaks or abrasions, but it may penetrate through intact skin as well. As it reaches the subepithelial layers, it begins to rapidly multiply and disseminate through the blood vessels and the lymphatic system [4], which is the hallmark of secondary stage of syphilis, in which generalized dissemination leads to the development of a generalized rash. In order to achieve the process of multiplication, the bacteria uses several flagella located in its periplasmic space for movement and its tip serves for attachment to host structures. Several substances have been discovered to be key pieces in this process, including several hemolysins, fibronectin, and laminin, which are used for adherence and cleavage of various host components. Normally, the immune system should recognize foreign pathogens through recognition of pathogen-associated molecular patterns (PAMPs), but because of practically absent expression of components on the outer membrane of the bacteria, cells, and receptors of the immune system are unable to detect them. As a result, it is free to replicate and disseminate into all tissues and organs, including the central nervous system and at some point, for unknown reasons, dendritic cells are able to recognize the antigen and induce a proper immune response, including stimulation of Th1 CD4+ T-Helper cells and interferon gamma (IFN-γ) [8]. Why the infection then reaches latent stages and how it is able to survive in hosts and cause tertiary infections with life-threatening complications in some cases remains unknown.

Prevention

Significant steps in terms of prevention can be made. Firstly, protection during sexual intercourse is shown to significantly reduce the possibility of transmission of syphilis, but other STDs as well [15]. Because syphilis can be transmitted by oral sex as well, reducing sexual contact that may be of risk is also an effective treatment strategy.

Summary

Syphilis is among the most common sexually transmitted diseases (STDs) diagnosed worldwide. It is caused by Treponema pallidum, which belongs to the group of spirochete bacteria [1]. Epidemiological data suggest that more than 30 million adults have this infection worldwide and more than 10 million new cases occur annually [2]. Humans are the only natural hosts and sexual contact is the primary mode of transmission of T. pallidum, while vertical transmission from mother to child is also possible. T. pallidum reaches the host through either intact or damaged skin and mucosa and is able to evade immune defenses through several mechanisms. The most important one, however, is the ability of bacteria to express very few molecules on their outer membrane, which limits the capacity of the innate immune system to recognize this pathogen and its antigens. As a result, the bacteria is able to roam freely in the extracellular space, make direct contact with host tissues and disseminate throughout the human organism. The clinical presentation of syphilis can be challenging due to the presence of many symptoms at various stages of the disease, but in general, this infection is classified into four stages. Primary syphilis includes development of a skin lesion (chancre) over the course of 10-14 days at the site where bacteria penetrated the tissues; Secondary syphilis reflects the dissemination of bacteria throughout the human body and is characterized by a maculopapular rash that initially develops on the trunk and extends to the extremities, including the palms and soles. The rash develops approximately 2-6 months after infection by T. pallidum and in addition to its maculopapular forms, several other skin lesions may be encountered. The development of pustules may be seen as the maculopapular rash further progress. In intertriginous areas, the maculopapular rash can progress into gray or white papillary formations known as condylomata lata [3]. Skin lesions may regress and then appear again within a few weeks, which is not uncommon. In addition to skin manifestations, various other symptoms may be present during this stage. Constitutional symptoms, such as nausea, vomiting, abdominal pain, weight loss, fever, myalgia, and arthralgia may be present, while cervical, axillary or inguinal lymphadenopathy may be encountered as well. The secondary stage is known to be the time when the patient is most infectious. In some patients, secondary syphilis can progress into a latent stage (third stage), and in rare cases, tertiary syphilis (fourth stage) may develop, which may cause severe, life-threatening cardiovascular and neurological manifestations. The diagnosis of patients with secondary syphilis can be made during the physical examination, aided by a thorough patient history, including recent sexual contact and previous exposure to carriers of syphilis. A definite diagnosis can be made by dark-field microscopy and through various serological tests. Human immunodeficiency virus (HIV) infection, but other STDs should be tested for as well in all individuals presenting with syphilis, as coinfection of these pathogens is frequent. Treatment of patients during the secondary stage of syphilis includes administration of benzathine penicillin G as a single dose of 2.4 million units intramuscularly, while alternative regimens exist for penicillin-allergic patients.

Patient Information

Syphilis is one of the most common sexually transmitted diseases worldwide and it is caused by a bacteria, Treponema pallidum. Global estimates suggest that more than 30 million people suffer from this infection and that every year, 10 million people contract this infection. It is almost exclusively transmitted by sexual intercourse, including oral, genital and anal, but transmission of syphilis from mother to child during pregnancy is also possible because the bacteria can breach the placental barrier and infect the fetus. However, syphilis is much more common among males, with most frequent rates observed among men who are having sex with men (MSM population). The course of this infection is divided into four stages: primary, secondary, latent stage and tertiary. The secondary stage of syphilis represents dissemination of bacteria throughout the body after their initial entry through the skin and subsequent spreading through blood vessels and the lymphatic system. It is the time period in which the infected individual is most prone to spreading the infection. The hallmark of secondary syphilis is the development of a rash over the entire body, which occurs between 2-6 months after contracting the spirochete. The rash firstly develops on the trunk and then spreads to the extremities. One of the main distinguishing features of this rash is that it spreads to the palms and soles as well. This rash is reddish-to-brown in color and consists of red-to-brown spots several millimeters in diameter. In intertriginous areas, such as the armpit, the area under the breasts, or the gluteal region, grayish-to-white elevations of the skin, known as condylomata lata, may develop. Flu-like symptoms, such as malaise, muscle and joint pain, fever and weight loss may appear a few days before the rash develops. Enlarged lymph nodes in the neck, armpits, and groins are frequently observed. In addition to the skin, secondary syphilis may cause symptoms related to hearing, vision, but also bone pain and gastrointestinal symptoms such as vomiting and diarrhea may develop. The diagnosis of syphilis in the secondary stage can be made through physical examination and observation of the rash that involves the palms and soles, but a definite diagnosis can be made by obtaining material from the rash for a specific microscopic evaluation called dark-field microscopy. This method implies investigation of bacteria through binding of fluorescent antibodies and their visualization in a dark field, as these bacteria cannot be seen in regular light microscopy. Other methods include detection of antibodies against Treponema pallidum in blood, as well as other tests that confirm their presence. Treatment includes administration of penicillin as a single dose intramuscularly, while patients who are allergic to penicillin may receive azithromycin, doxycycline or tetracycline. In very rare cases, a reaction to therapy, known as Jarisch-Herxheimer reaction, may develop and includes symptoms such as fever, flushing, headaches and blood pressure disturbances, which occurs as a result of interaction between the degrading bacteria and the host immune system. Significant steps in prevention can be made, through the use of protection during intercourse, but more importantly, avoiding sexual contact that may be of risk, since secondary syphilis may eventually cause life-threatening complications if it reaches the tertiary stage of the disease.

References

Article

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Last updated: 2019-07-11 21:29