Clinical Manifestations
A painless ulcer (chancre) arises, with a rolled, indurated border (Fig. 28.15).
Most often presents on or near the glans penis in men and less commonly on the shaft of the penis.
In women the labia majora or minora, the clitoris, or the posterior commissure are the sites of predilection; however, visible primary lesions are rarely reported or found.
The base of the ulcer is “clean” (not purulent) unless it is superinfected.
Diagnosis
Nontreponemal serologic tests such as Venereal Disease Research Laboratory (VDRL) and the rapid plasma reagin (RPR) tests, both of which detect antibodies to cardiolipin, are the most commonly used. Positive results can be titrated providing a tool for determining response to therapy. Such tests may not become positive until 1 or 2 weeks after the chancre has appeared. Other drawbacks include both false-positive as well as false-negative results. False-negative results may occur due to the prozone phenomenon.
Treponemal-specific tests such as the fluorescent treponemal antibody absorption test (FTA-ABS) and other treponemal-specific tests offer nearly 99% specificity and sensitivity.
Darkfield examination of chancre traditionally afforded the fastest way to make the diagnosis of primary syphilis; however, this test has almost completely fallen out of use due to the necessity of the presence of a darkfield microscope and the current lack of skills required to use this device.
Differential Diagnosis 
Management 
Helpful Hints Clinical Manifestations
Secondary lesions appear 2 to 6 months after primary infection; chancre may still be present (15% of cases).
Scaly, erythematous, oval, papulosquamous lesions appear (Fig. 28.16).
Lesions are generally asymptomatic, but the patient may have fever, generalized adenopathy, and mild systemic symptoms.
Mucous patches of the tongue may be noted (Fig. 28.17). (See also Fig. 21.7.) The so-called “split papules” may also be seen at the corners of the mouth.
“Moth-eaten,” diffuse alopecia (Fig. 28.18) and condyloma latum (Fig. 28.19) can also seen in secondary syphilis.
Lesions are widespread and may include the palms (Fig. 28.20), soles, scalp, and mucous membranes.
Secondary lesions fade within 2 to 6 weeks, after which the latent stage begins.
Diagnosis (see discussion above for primary syphilis)
The diagnosis is often suggested by the clinical presentation.
VDRL and the RPR usually at a titer greater than 1:16; treponemal-specific tests such as FTA-ABS and other treponemal-specific tests confirm the diagnosis.
A skin biopsy with silver or immunoperoxidase stain may also confirm the diagnosis.
Latent syphilis is manifested by positive serologic tests for nontreponemal and treponemal antibodies in the absence of clinical manifestations. It is divided into early latent syphilis and late latent syphilis.
Early latent syphilis is syphilis documented to be of less than 1 year in duration and is treated with the same regimen as primary and secondary infections.
The duration of late latent syphilis is more than 1 year or is unknown. The recommended treatment is benzathine penicillin 2.4 million units intramuscularly weekly for 3 weeks.
HIV-infected patients with latent syphilis of any duration should have a cerebrospinal fluid examination to rule out neurosyphilis before treatment.
Congenital syphilis can affect infants born to mothers with: (1) untreated syphilis, or (2) syphilis treated during pregnancy with erythromycin, or (3) syphilis treated less than 1 month before delivery, or (4) syphilis treated with penicillin without a four-fold decrease in serologic titer.
The CDC recommends that all pregnant women be tested for syphilis at least once during pregnancy and at the time of delivery in at-risk populations.
Pityriasis Rosea
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Outline