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SAEM Clinical Image Series: Guess Who’s Back?

Posted by Sherin Mahrat on

A 27-year-old male with no significant past medical history presented to the emergency department with one week of progressively worsening, non-pruritic, and intermittently painful rash to his bilateral dorsal and plantar feet. The patient also described lesions to his left inguinal region and scrotal sac. There was no fever, chills, nausea, vomiting, chest pain, or shortness of breath. The patient was sexually active with men and women, with inconsistent condom use.

Additional Images

Physical Exam

Vitals: BP 161/100; HR 113

General: Alert, awake, oriented, and non-toxic without acute distress

Skin:

  • Multiple copper lesions to the bilateral soles and dorsal surfaces of the feet
  • Scrotal and penile chancres and multiple wart-like lesions to the peri-rectal region

The remainder of the exam is unremarkable.

Case Question: Given the findings displayed in the images, what is the most likely diagnosis?

Secondary syphilis

Laboratory Data

Rapid plasma reagin (RPR), general condition gonococcus (GC)/Chlamydia, and human immunodeficiency virus (HIV) serologies were sent.

Post-visit results showed:

Qualitative RPR: Positive

Quantitative RPR: 1:64

HIV and GC/Chlamydia: negative

Labs were otherwise normal.

Case Question: What is the name of the anal lesions presented in the image?

Condylomata lata syphilis

A sexually transmitted infection caused by bacterium Treponema pallidum, is notoriously variable in its clinical presentation and has experienced a resurgence in recent years.

Primary syphilis can appear 3 to 90 days after exposure and manifests as a painless, non-pruritic chancre at the point of contact.

Secondary syphilis occurs 2 to 10 weeks after primary infection and commonly presents with systemic signs.

Case Discussion

Take-Home Points

  • Syphilis has reemerged following a steady decline toward the end of the last century; it is therefore imperative that physicians be able to identify both typical and unusual cases given its recent resurgence and tendency to mimic other pathology (1, 2).
  • Condylomata lata is a cutaneous manifestation of secondary syphilis and are often misdiagnosed as genital warts or condylomata acuminata.

References

  1. Crouzy F, Alvarez V, Gex G, Troillet N. Unusual presentations and pitfalls of secondary syphilis: osteitis, pneumonia and malignancy. BMJ Case Rep. 2015;2015:bcr2015210618. Published 2015 Oct 26. doi:10.1136/bcr-2015-210618. PMID: 26504092
  2. Henao-Martínez AF, Johnson SC. Diagnostic tests for syphilis: New tests and new algorithms. Neurol Clin Pract. 2014;4(2):114–122. doi:10.1212/01.CPJ.0000435752.17621.48. PMID: 27606153

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2020 SAEM Annual Meeting | Copyrighted by SAEM 2020 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

Author information

Sherin Mahrat

Medical Student
University of Illinois College of Medicine

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