Case 3

HPI: A 22 y/o male presented with fever & diffused rash x 2d. Rash is pruritic & nontender. He also c/o gen malaise, myalgia & sore throat. He denies N/V/D, neck stiffness, HA, joint pain, cough, CP or SOB.

PMH: none

All: NKDA

Soc: tobacco, EtOH

PE: Gen – NAD

HEENT – PERRLA, EOMI, mmm, supple neck, nontender L cervical LN

CV – RRR, no murmur

Resp – CTAB

Abd – soft, NT/ND, +BS

Ext – no joint tenderness or diffusion

Skin – diffused maculopapular rash as demonstrated in the picts below

Labs: CBC, Chem, LFT, CXR, UA – all wnl

What’s your diagnosis?

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Answer: Secondary Syphilis

As most of you already guessed – this is 2° syphilis, which “classically” involves the palms of the hands & soles of the feet. Don’t forget that “classic presentations” occurs less than 20% of the time. When asked if the patient had “any problems” with his genitals in the past, he promptly answered “no.” Remember that the chancre of 1° syphilis is painless, and most people won’t recall having it.

2° syphilis usually includes a localized or diffuse mucocutaneous rash, which may be a macular, papular, or pustular, and a generalized nontender lymphadenopathy. They tend to be distributed on the trunk & prox extremities, and, of course, “classically” involves the palms & soles. Papules may coalesce to form condylomata lata.

The rash is highly contagious. Constitutional symptoms include fever, malaise, sore throat, HA, & myalgia; may also develop alopecia. VDRL & RPR are nearly 100% + in 2° syphilis. Tx if symptoms < 1 yr - single dose benzathine PCN G 2.4 million U IM once in 2 injection sites; if > 1 yr - 3 weekly doses. If PCN allergic, tx w/ a tetracycline or macrolide.

Key points:

- Any rash involving any part of the hands & feet – think syphilis or RMSF!!!

- Wear gloves!

- “The physician who knows syphilis knows medicine.” – Sir William Osler