1. Several weeks ago, this 56-year-old man noticed numerous asymptomatic round macules and papules on his palms and soles, many with scaly peripheral margins. Similar lesions are noted on the penile corona and glans. There is a faint but definite morbiliform, blanchable pink rash covering most of the patient’s trunk, taking on a “shawl” distribution across the shoulders. The patient is exclusively homosexual and recently engaged in high-risk sexual activity.
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Diagnosis: It would be hard to imagine a more classic example of secondary syphilis than was seen in this case, occurring in a patient so obviously at risk. But it’s only “obvious” if you’re ready and aware of how syphilis manifests. It also helps if you understand how common it is and who’s likely to get it.
TAKE-HOME LEARNING POINTS
• Palmar and plantar rashes are unusual and should prompt the examiner to expand the history and physical.
• Secondary syphilis, though uncommon, is far from rare, especially among gay men engaging in high-risk sexual behavior.
• It’s common for the patient to deny the appearance of the chancre of primary syphilis, and such a lesion would be long gone by the time those of secondary syphilis manifest.
• Conditions involving the skin should be seen by a dermatology provider, regardless of location. This includes diseases of the skin, hair, nails, oral mucosa, genitals, feet, or palms. One potential exception is the eye itself, though most diseases “of the eye” are, in reality, diseases of the periocular skin—and belong with a dermatology provider.
For more information on this case, see “When There’s More to the Story ….” Clin Rev. 2013;12;2013(12):W2.