Photo Rounds
Single nontender ulcer on the glans
The patient’s history and the clinical appearance of the ulcer led to the diagnosis of this re-emerging condition.
Diagnosis: Secondary syphilis
The appearance of the genital and perianal lesions was consistent with condylomata lata—a cutaneous sign of secondary syphilis—rather than genital warts. The presence of a rash on the patient’s trunk and extremities further supported this diagnosis. We did a rapid plasma reagin (RPR) test and a Treponema pallidum particle agglutination test; we also tested for human immunodeficiency virus (HIV). The patient’s RPR titer was 1:128, and the T pallidum antibody test came back positive. HIV-1 and HIV-2 serology were negative.
Appearance of the lesions was a giveaway. Condylomata lata are flat-topped, broad papules that are usually located on folds of moist skin (particularly the genitals and anus), and have a smooth, gray, moist surface. Although they can be lobulated, they do not have the classic digitate projections that are characteristic of genital warts. A nonpruritic, symmetric, “raw ham”-colored papular eruption on a patient’s trunk, palms, and soles is also characteristic of secondary syphilis.1 In this case, the reticular pattern on the patient’s chest represented the commonly seen lenticular rash of secondary syphilis.
Cutaneous lesions of secondary syphilis contain numerous spirochetes (T pallidum) and are highly infectious. Systemic symptoms of secondary syphilis may include fatigue, generalized lymphadenopathy, arthralgia, myalgia, pharyngitis, and headache.
Some patients may report having a recent chancre—a painless, self-limiting ulcer in the genital area—which is characteristic of primary syphilis (see “Single nontender ulcer on the glans,” J Fam Pract. 2017;66:253-255). For more on the stages of syphilis, see the TABLE2. Our patient did not remember ever having a chancre.
Increase in cases. Rates of primary and secondary syphilis have increased in the past decade. In 2014, approximately 20,000 syphilis cases were reported—a record high since 1994.3 Men who have sex with men are particularly affected; however, increases in infection rates have also been noted in women and across people of all ages and ethnicities.3
Rule out other causes of genital lesions
Condyloma acuminata, commonly called genital warts, are localized human papilloma virus (HPV) infections that appear as discrete, gray to pale pink, lobulated papules that may coalesce to form a large, cauliflower-like mass. They are sexually transmitted and commonly involve the genital and anal areas. While physicians may confuse condylomata lata with genital warts, diffuse skin rashes and constitutional symptoms are not usually seen with genital warts.4
Fordyce spots are small, whitish, raised papules on the glans or the shaft of the penis or the vulva of the vagina. They may also appear on the lips and oral mucosa. They are a result of prominent sebaceous glands and are harmless. They are not infectious or sexually transmitted.5,6
Lymphogranuloma venereum is an uncommon sexually transmitted disease caused by Chlamydia trachomatis. It is characterized by genital papules or ulcers, followed by bilateral, suppurative, inguinal adenitis known as buboes. The buboes may breakdown, form multiple fistulous openings, and discharge purulent material.6
Acute HIV may present with flu-like symptoms and well-circumscribed maculopapular rashes on the face, neck, and upper trunk. The palms and soles may also be affected. Patients with HIV may also develop genital plaque-like lesions from herpes simplex virus-2, genital warts from HPV, molluscum contagiosum, and, not uncommonly, anogenital malignancies.7,8
Confluent and reticulated papillomatosis (CARP) is a disorder that occurs predominantly in young adults and teenagers, with cosmetically displeasing brown scaling macules that may coalesce to form patches or plaques affecting the neck, chest, back, and axillae. It is often mistaken for tinea versicolor.9 In this case, the eruption on the chest closely resembled CARP, but a diagnosis of CARP would not have explained the genital lesions.