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D32 Dermatology
Infections
Toronto Notes 2019
Table 20. Stages of Syphilis
Natural History of Untreated Syphilis
• Inoculation
• Primary syphilis (10-90 d after infection)
• Secondary syphilis (simultaneous to
primary syphilis or up to 6 mo after healing
Primary Syphilis
Secondary Syphilis
Clinical Presentation
Single red, indurated, painless chancre, that develops into painless ulcer with raised border and scanty serous exudate
Chancre develops at site of inoculation after 3 wk of incubation and heals in 4-6 wk; chancre may also develop on lips or anus
Regional non-tender lymphadenopathy appears <1 wk after onset of chancre
DDx: chancroid (painful), HSV (multiple lesions)
Presents 2-6 mo after primary infection (patient may not recall presence of primary chancre)
Associated with generalized lymphadenopathy, splenomegaly, headache, chills, fever, arthralgias, myalgias, malaise, photophobia
Lesions heal in 1-5 wk and may recur for 1 yr 3 types of lesions:
1. Macules and papules: flat top, scaling, non-pruritic, sharply defined, circular/annular
rash (DDx: pityriasis rosea, tinea corporis, drug eruptions, lichen planus)
2. Condyloma lata: wart-like moist papules around genital/perianal region
3. Mucous patches: macerated patches mainly found in oral mucosa
Extremely rare
3-7 yr after secondary
Main skin lesion: ‘Gumma’ – a granulomatous non- tender nodule
Investigations
CANNOT be based on clinical presentation alone
VDRL negative – repeat weekly for 1 mo
FTA-ABS test has greater sensitivity and may detect disease earlier in course Dark field examination – spirochete in chancre fluid or lymph node aspirate
VDRL positive
FTA-ABS +ve; –ve after 1
yr following appearance of chancre
Dark field +ve in all secondary
As in primary syphilis, VDRL can be falsely negative
Management
Penicillin G, 2.4 million units IM, single dose
As for primary syphilis
of primary lesion)
• Latent syphilis
• Tertiary syphilis (2-20 yr)
Latent Syphilis
70% of untreated patients will remain in this stage for the rest of their lives and are immune to new primary infection
Tertiary Syphilis
Penicillin G, 2.4 million units IM weekly x 3 wk
GONOCOCCEMIA
Clinical Presentation
• disseminatedgonococcalinfection
• hemorrhagic,tender,pustulesonapurpuric/petechialbackground
• commonsites:distalaspectsofextremities
• associatedwithfever,arthritis,urethritis,proctitis,pharyngitis,andtenosynovitis • neonatalconjunctivitisifinfectedviabirthcanal
Etiology
• Neisseriagonorrhoeae
Investigations
• requireshighindexofclinicalsuspicionplaysbecausetestsareoftennegative • bacterialcultureofblood,jointfluid,andskinlesions
• jointfluidcellcountandGramstain
Management
• notifyPublicHealthauthorities
• screenforotherSTIs
• cefixime400mgPO(drugofchoice)orceftriaxone1gIM
HSV
• seeViralInfections,D29
HPV
• seeViralInfections,D30