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Secondary syphilis: The great imitator can’t be forgotten
Rev Assoc Med B ras 2017; 63(6):481-483 481
IMAGE IN MEDICINE
Secondary syphilis: The great imitator can’t be forgotten
Clarissa Prieto Herman Reinehr1*, Célia L uiza Petersen Vitello Kalil2, Vinícius Prieto Herman Reinehr3
1MD, Dermatologist, Member of the Brazilian Society of Dermatology, Master’s Student at the Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
2Dermatologist, Member of the Brazilian Society of Dermatology, Porto Alegre, RS, Brazil
3MD, General Practitioner, Porto Alegre, RS, Brazil
Summary
Study conducted at Clínica Dermatológica
Célia Kalil, Porto Alegre, RS, Brazil
Article received: 11/7/2016
Accepted for publication: 12/4/2016
*Correspondence:
Address: Rua Félix da Cunha, 1.009,
conj. 401
Porto Alegre, RS – Brazil
Postal code: 90570-001
Syphilis is an infection caused by Treponema pallidum, mainly transmitted by
sexual contact. Since 2001, primary and secondary syphilis rates started to rise,
with an epidemic resurgence. The authors describe an exuberant case of second-
ary syphilis, presenting with annular and lichen planus-like lesions, as well as
one mucocutaneous lesion. Physicians must be aware of syphilis in daily practice,
since the vast spectrum of its cutaneous manifestations is rising worldwide.
Keywords: cutaneous syphilis, sexually transmitted disease, benzathine penicil-
lin G, Treponema pallidum.
Introduction
Syphilis is an infection caused by Treponema pallidum, a spi-
rochete bacterium transmitted mostly by sexual contact.
Spirochetes penetrate skin or mucosa in areas of micro-
trauma and disseminate systemically within 24 hours.1
The incidence of syphilis started to rise again in 2001,
with epidemic resurgence especially among men who have
sex with men and HIV-infected patients.2 More specifi-
cally, the incidence of syphilis has tripled in the last 10
years.3 The authors describe an exuberant case of second-
ary syphilis.
Case report
A previously healthy 63-year-old man presented with cu-
taneous asymptomatic lesions that appeared approxi-
mately three months before, first on the hands and wrists,
and later affecting feet, thighs and lips. During the clin-
ical examination, sharply demarcated hyperkeratotic,
violaceous scaly plaques on his hands and feet, including
annular and well-circumscribed lesions on the palms and
soles were observed (Figure 1); also, the patient showed
a papule located at the right angle of the upper lip (Figure
2). First hypotheses included lichen planus and secondary
syphilis. He denied previous genital ulceration, but re-
ported unprotected sex in the past. Laboratory tests re-
vealed a venereal disease research laboratory test (VDRL)
titer of 1:32 (normal value < 1:2) and positive tests for
syphilis-specific IgM and IgG antibodies. Serology was
negative for human immunodeficiency virus and hepati-
tis B and C. A diagnosis of secondary syphilis was con-
firmed and the patient was treated with three weekly in-
tramuscular injections of benzathine penicillin G 2.4×106
IU.4 The patient was advised to contact his sexual partners
so that they could seek medical evaluation. One month
after treatment, the lesions resolved (Figure 3).
Discussion
Secondary syphilis, the most florid stage of the disease,
called “the great imitator,” has a variety of cutaneous
manifestations.5 The onset of secondary syphilis varies
but typically occurs two to eight weeks after the disap-
pearance of the primary chancre. This stage can present
with systemic symptoms and painless generalized ade-
nopathy. If left untreated, secondary syphilis tends to
progress to a latent stage, but clinical manifestations can
recur for up to five years if not treated. 1
The first cutaneous manifestation of secondary syph-
ilis is a macular nonpruritic rash, composed of small and
well-defined erythematous and/or hyperpigmented lesions
(roseola syphilitica) that spontaneously resolve in 20 to 40
days.6 Some time after that, the classic exanthema of sec-
ondary syphilis occurs: a diffuse nonpruritic maculopapu-
lar rash that frequently involves palms, soles and scrotum.
Variants of classic secondary syphilis rash include annular,
pustular, nodular, nodulo-ulcerative, berry-like, corymbi-
form, photosensitive systemic lupus erythematosus-like,
lues maligna, leukoderma and chancriform presentations.6
The classic maculopapular rash can mimic lichen
planus, with violaceous flat-topped papules on the wrists,
lower legs and acral sites, as observed in our case.7 The