Case: A 41 year old male with one week of non-pruritic palmar rash that started on his trunk and spread to his hands. He has no history of travel, fever, joint pains, or medication use. What is your diagnosis for this palmar rash? Click on the image for a larger view.
Poll Results
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Palmar rash from secondary syphilis
Explanation
“The Great Imitator” is making a comeback. Between 2011 and 2012, the number of reported primary and secondary syphilis cases increased 12.1%. From 2005 to 2013 the number of cases nearly doubled.1 In 2012, 75% of the reported primary and secondary syphilis cases were among men who have sex with men.2
The rash of secondary syphilis is generally pink or dusky red and papular. The skin is indurated and there is often a superficial scale on the lesions. Though it typically involves the palms and soles, it can start on the trunk and spread to the entire body.3
A brief review of the stages of syphilis4:
| Stage | Time Course | Clinical Manifestations |
| Primary | ~21 days from innoculation | Painless chancre |
| Secondary | 3-6 weeks after end of primary stage | Fever, headache, lymphadenopathy, malaise, rash, sore throat |
| Tertiary | 3-20 years after infection | Dementia, granulomatous lesions (gummata), meningitis, neuropathy (tabes dorsalis), thoracic aneurysm |
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Master Clinician Bedside Pearls
Stuart Swadron, MD – Professor of Emergency Medicine, Keck School of Medicine of the University of Southern California (provided to ALiEM and recorded by Swadron, 2014)
Author information
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