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Primary and Secondary Syphilis

by John Fisher, MD
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    00:01 So let's talk about the clinical features of syphilis, and there are many.

    00:07 First, primary syphilis.

    00:09 At the sight of inoculation, we start out with a flat lesion called a macule which quickly develops into an elevated lesion called a papule, and then into a painless ulcer or chancre.

    00:29 In men, this chancre will appear on the prepuce, the coronal sulcus, the shaft the corona and the glans in descending order of frequency.

    00:41 Here are some examples of chancres on the glans, shaft, and coronal sulcus the prepuce and the labia in women.

    00:53 This ulcer, one would think, would be painful but its actually painless and non-tender.

    01:01 It may be that the spirochetes infiltrate the sensory nerves and that's why it's not painful.

    01:11 And so lesions that are non-painful are the most characteristic.

    01:20 The one exception would be a chancre in the anal area is generally very painful.

    01:27 In patients who have HIV infection they may have actually multiple chancres.

    01:34 Because they're not symptomatic, they may not even be recognized by the person who's been infected.

    01:42 It may heal without recognition within 3-6 weeks.

    01:49 That's when we find the development of secondary syphilis.

    01:54 Secondary syphilis is the reason that this organism has been called the great imitator.

    02:01 Because it can appear in a wide variety of anatomical locations and mimic lots of diseases.

    02:10 But the bottomline is that the skin and mucous membranes are affected in 95% of individuals with syphilis.

    02:21 They have rashes.

    02:25 The characteristic rash -- and you can take this to the bank -- is a papulosquamous eruption, meaning that it's an elevated lesion that is scaly.

    02:38 That is what papulosquamous means.

    02:42 However, the lesions can be macular or flat, they can be papular, annular, pustular, or the worst form, Lues maligna, which is demonstrated in the lower panel, which is essentially an ulcerative form of pustular secondary syphilis.

    03:08 So more about secondary syphilis.

    03:11 Sometimes you can see lesions on the mucosa such as the oral mucosa or the labia.

    03:22 And then we can find things that are determined Condylomata lata.

    03:31 Now Condylomata acuminata are venereal warts, which is a subject for another presentation.

    03:39 Condylomata lata are syphilitic and they are very highly contagious, teeming with organisms.

    03:48 Now, these are elevated, sort of exophytic lesions, as you can see in these panels.

    03:58 And at the same time, the patients usually have systemic symptoms.

    04:01 They have low-grade fever and malaise.

    04:04 They have arthralgias, myalgias, and generalized lymphadenopathy.

    04:12 And I don't think physicians today are as adept as physicians before my era of feeling for swollen lymph nodes.

    04:24 There's a real art to detecting axillary lymph nodes.

    04:28 And in my experience, axillary lymphadenopathy is really quite common in syphilis and in an HIV infection.

    04:37 Secondary syphilis can also involve the mucosa of the GI tract.

    04:42 For example, it can heavily infiltrate the stomach, causing the stomach to be thick with or without ulcers.

    04:51 And it can be mistaken for a stomach cancer.

    04:57 The patients will often complain of epigastric pain and early satiety.

    05:03 Now, the early satiety can be explained because the normal stomach when food comes in, stretches.

    05:11 Whereas a thick wall of a stomach doesn't handle food as it comes in and the person who's affected may feel like they fill up too fast.

    05:24 Or they may have frank nausea and vomiting.

    05:28 When secondary syphilis involves the liver, you would expect an increase in the liver-associated enzyme especially the alkaline phosphatase.

    05:39 But symphtomatic hepatitis is pretty rare in secondary syphilis.

    05:45 Unfortunately, the eye can be involved and all structures from anterior to posterior may be involved.

    05:56 The most characteristic is something called interstitial keratitis, which involves scarring of the cornea.

    06:06 But the infection may be in the anterior chamber and cause an iritis or anterior uveitis.

    06:14 It can be in the vitreous or choroid and cause a posterior uveitis or chorioretinitis, or an optic neuritis.

    06:24 Now just an aside, the young people I teach at the medical school -- residents, interns and students -- are not as in the habit of carrying ophthalmoscope with them as my teachers taught me.

    06:39 And they're missing opportunities to make diagnosis with the ophthalmoscope.

    06:46 For example, the optic disc in optic neuritis becomes stark white.

    06:55 The normal color of the optic disc is sort of bone-colored.

    07:01 And if you were to look with an ophthalmoscope and saw that the optic disc was stark white, you've made the diagnosis of optic neuritis.

    07:15 The ear can also be involved with hearing loss of a sensorineural nature.

    07:23 The patient may complain of tinnitus or ringing in the ears or frank vertigo if the utricle and saccule are involved.

    07:33 Worst of all, the brain can be affected.

    07:38 And in secondary syphilis, you can actually have a syndrome that looks like meningitis or a syndrome like a stroke.

    07:48 The bones can be involved and the classic is periostitis -- the outer surface of the bone.

    07:56 The tibia is the most frequent bone affected by syphilis, and there is an example of syphilitic periostitis, the so-called saber shins.

    08:10 But the sternum, the skull, and the ribs can also be affected in secondary syphilis.


    About the Lecture

    The lecture Primary and Secondary Syphilis by John Fisher, MD is from the course Genital and Sexually Transmitted Infections. It contains the following chapters:

    • Primary Syphilis
    • Secondary Syphilis

    Included Quiz Questions

    1. Papulosquamous
    2. Macular
    3. Vesicular
    4. Pustular
    5. Scarlatiniform
    1. 75%
    2. 100%
    3. 50%
    4. 25%
    5. 10%
    1. Painless mucosal ulcer at site of inoculation
    2. Localized tender lymphadenopathy
    3. Stinging vesicular lesion at the site of incoulation
    4. Urinary frequency
    5. Pustular discharge
    1. Interstitial keratitis
    2. Iritis
    3. Optic neuritis
    4. Anterior uveitis
    5. Chorioretinitis
    1. Early satiety due to gastric mucosal thickening
    2. Lower intestinal bleeding
    3. Diarrhea
    4. Constipation
    5. Colonic polyposis
    1. Condylomata accumulatens
    2. Condulomata lata
    3. Generalized lymphadenopathy
    4. Fever
    5. Arthralgias
    1. Tibia
    2. Otic bones
    3. Sternum
    4. Skull bones
    5. Ribs

    Author of lecture Primary and Secondary Syphilis

     John Fisher, MD

    John Fisher, MD


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    very detailed but right to the point
    By Sujy S. on 19. January 2018 for Primary and Secondary Syphilis

    Dr. Fisher is very thorough in explaining certain details but also very direct to point out important information.