Diagnostic Hallmarks Distribution: trunk and extremities, special predilection for the palms, soles, face, and genitalia White plaques on mucous membranes Patchy alopecia Lymphadenopathy Positive serologic tests for syphilis Clinical Presentation The eruption of secondary syphilis is characterized by the presence of numerous non confluent, dome-shaped, red papules 1 to 4 mm in diameter.
The amount of scale present is variable.
Smaller lesions tend to have little visible scale, whereas larger lesions may be quite scaly.
The papules sometimes coalesce to form small annular lesions, but the formation of large plaques almost never occurs.
Annular lesions are particularly likely to be found on the face and genitalia.
The papules of secondary syphilis are randomly distributed on the trunk and extremities.
In addition, they are regularly found on the face, palms, and soles.
In fact, palmar lesions are sufficiently characteristic as to almost always warrant a serologic test for syphilis regardless of the remainder of the clinical picture.
Papules that occur on the palms and soles are often larger, firmer, and more brown-red than are those found elsewhere.
Itching, when present at all, is not usually troublesome.
Other distinctive lesions of secondary syphilis include white plaques on the mucous membranes and flat-topped, red or white, moist papules (condylomata lata) in intertriginous sites.
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.
A clinical diagnosis of secondary syphilis must be done either by identification of typical spirochetes on dark-field examination or through serologic testing.
The histologic pattern on biopsy is also quite distinctive, and from time to time cases are first identified during examination of a biopsy specimen taken from an otherwise-unrecognized papulosquamous eruption.
Course and Prognosis The ulcer of primary syphilis (chancre) appears 2 to 3 weeks after exposure to an infected person .
It reaches its maximum size of 1 to 2 cm quickly and then remains stable until it undergoes spontaneous resolution 3 to 4 weeks later.
The eruption of secondary syphilis begins at about this time, i.
e.
, approximately 6 weeks after original contact.
Occasionally, there is a short period of overlap during which both primary and secondary lesions are present.
Of course, if the primary lesion occurs in a hidden site, the first apparent evidence of infection will be the secondary eruption.
The lesions of secondary syphilis contain motile spirochetes, and thus contagion, particularly from moist lesions, is possible.
Left untreated, the lesions of secondary syphilis remain in place for about 2 months and then gradually undergo spotaneous resolution.
Thereafter, over the next 6 to 12, ollilts, recurrent crops of secondary lesions may redevelop.
Secondary syphilis is not simply a cutaneous infection.
Systematic involvement in the form of lymphadenopathy, uveitis, hepatitis, or glomerulonephritis is frequently present.
About one-third of the patients with secondary syphilis who go untreated develop tertiary disease.
Another one-third remain free of clinical disease but continue to have serologic evidence of activity (latent syphilis).
The final one-third appear to undergo spontaneous clinical and serologic cure.
Treatment of patients with primary or secondary syphilis excepting sometimes those with immunodeficiency) effectively halts all clinical progress of the disease.
The serologic tests in these patients gradually become negative over a 12- to 36 month period.
Unfortunately, little or no permanent immunity is conferred as a result of primary or secondary reinfection, and thus reinfection is quite possible.
Pathogenesis Syphilis is caused by the spirochete Treponema pallidum.
This organism is passed from person to person during close skin-to-skin contact such as occurs during sexual clivity.
Spirochetemia results in the subsequent presence or infectious organisms in the mucocutaneous lesions of secondary syphilis.
Antibody reaction to infections with T.
pallidum is brisk, but this type of immunologic response does not result in resolution of the disease; in fact, reinfection is possible even when antibodies are present.
The formation of these antibodies, together with the continued presence of treponemal antigen, results in the development of circulating immune complexes that are Ihen responsible for some of the systemic symptoms and signs of the disease.
Therapy Penicillin is the treatment of choice for syphilis.
Penicillin is only effective during the process of microbial replication, and since T.
pallidum replicates rather slowly, serum levels must be maintained for 10 to 20 days.
This is most conveniently accomplished through the use of intramuscularly administered benzathine penicillin.
The product Bicillin L-A should be specified, since Bicillin C-R contains a 50% mixture of short-acting procaine penicillin.
Some authorities suggest that for primary and secondary syphilis, 2.
4 million units be given in a single injection.
Most clinicians, however, administer an additional 2.
4 million units 1 week later.
Tetracycline 2.
0 g/day for 15 days can be used for patients allergic to penicillin.
After treatment, serologic tests for syphilis should be monitored at 3-month intervals until the titer of antibody has returned to zero.
A rising titer following treatment suggests reinfection and the need for retreatment.