Meenakshi Mohanram MD, Asst Prof, Dept of Dermatology, Chettinad Hospital & Research Institute, Chennai, India on May 22, 2011
This case is interesting because both patients had itching. Secondary syphilitic lesions are said to be non itchy.In tropics actinic lichen planus can present with similar itchy lesions on face.I agree that syphilis can present in many ways.
Alexander Wong, MD, FRCPC.
Internal Medicine & Infectious Diseases,
Schulich School of Medicine,
University of Western Ontario,
London, Ontario, Canada on May 22, 2011
The perineal lesions look pretty classic for
condyloma lata although I will have to admit that I've not seen
this personally as yet (we have some syphilis circulating up here but
Secondary syphilis can cause a wide range of lesions and
rash including nodular and annular type forms, and if they are
co-infected with HIV they can present in weird and atypical sorts of
ways as opposed to the usual maculopapular rash that everyone always
thinks about and pictures in their mind.
I don't have much to add in
terms of differential diagnosis from an infectious diseases perspective that would cause both lesions on the face and perineal lesions like this.
Would suggest that all of the usual STD testing be
performed in addition to syphilis serology. So I would add HIV serology, HBV / HCV serology, and urine
/ genital samples for GC / chlamydia to the workup. Treatment would be with benzathine penicillin, one dose typically suffices for primary and secondary syphilis.
David Elpern MD, Dermatologist, The Skin Clinic, Williamstown, MA, USA on May 22, 2011
Lest we forget! This is an extraordinarily important presentation. Syphilis has been called the great imitator -- It was probably Osler who said something like "to know syphilis to know (all of) medicine. The overuse of antibiotics in the West may partially treat this disease and push it further from our ken. I haven't diagnosed a case of syphilis in 15 years and wonder how many I may have missed. I think you should write this up for publication in a major journal somewhere -- perhaps in a Malaysian journal since it may well be that in your country the sex workers have a high incidence of syphilis (and possibly HIV as well).
Fadi Hajjaj MD, Dermatologist, Abu Dhabi, UAE on May 22, 2011
Thank you very much for presenting this interesting case. A message to take home is: take a detailed sexual history in any patient presenting with annular plaques around the mouth!!
The "great imitator" should always be in the back of the physician's mind when encountering with an odd rash.
Julian Manzur MD, Professor, Department of Dermatology, Havana, Cuba on May 22, 2011
I enjoy your presentation very much. Answering the questions:
1) Yes, I have seen, but more then 30 years ago, two patients with large condylomata of the anogenital area. Very similar to your patient.
2) We treat all the sexual contacts with positive or negative serology with the same treatment of the patient. In patient like this (secondary syphilis) all the contacts since 6 months ago. Tracing is crucial
3) We treat primary, secondary and early latent syphilis in penicillin allergic patients with doxycycline 100 mg twice daily for 14 days, tetracycline or erythromyin 500mg four times a day for 14 days. We use Ceftriaxone (Rocephin) usually in pregnant women. Of course never tetracycline or doxycycline.
Anand Pemmulu MD Honorary Tutor, Cardiff University School of Medicine, Cardiff, Wales, UK on May 22, 2011
The first case is interesting for the fact that the condylomata lata are quite florid. I recently had written up another secondary syphilis case which had typical granuloma annulare type lesions on the penis with added 'clean cut ham' appearance on the palms and soles for added effect.
Ted Rosen MD Professor of Dermatology, Baylor College of Medicine, Houston, TX, USA on May 22, 2011
This is classic secondary syphilis. The non specific biopsy is most consistent with this as well. Sarcoid, GA, Wegener's granulomatosis or annular lichen planus could be in the differential. One of the lesions on face or scalp could even be epithelioid sarcoma or desmoplastic trichepithelioma, but not this many! Syphilis is the only thing these presentations fit.
Carlos Garcia MD, Associate Professor, Department of Dermatology, Univeristy of Oklahoma, Oklahoma City, Oklahoma, USA on May 23, 2011
Thanks for sharing such great pictures! I rarely see syphilis any more, and most of my cases have presented with scaly papules on trunk, palms, and soles.
These condylomata lata are very large and atypical. Has anyone seen such florid ones? NO, I HAVE NOT
Should the wife of patient no.1 be treated even if her VDRL is negative? YES
Do your patients still undergo skin test for penicillin allergy? NO
Bhushan Kumar, MD, FRCP (Edin.), FRCP (London),
Former Prof. & Head,
Department of Skin, STD & Leprosy,
PGIMER, Chandigarh on May 31, 2011
1. The condylomas can definitely be as big as shown - of course it does not happen often.
2. The wife can only be followed and VDRL repeated – if she becomes positive only then she is to be treated. This is the best medical practice/ethics. However, in practice for epidemiological purposes all contacts should be treated.
3. Testing for penicillin is strongly recommended. In sensitive individuals – other drugs can be given- but a more stringent follow up is essential. Desensitization procedure as recommended by CDC is hardly ever practiced- but one can try it if you have the patience and the time.