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{{Syphilis}}
{{Syphilis}}
==Overview==
The physical examination findings of syphilis are described according to the stage of syphilis which includes non-tender [[chancre]] in primary syphilis followed by [[rash]] and generalized [[lymphadenopathy]] in secondary syphilis. Physical examination findings in tertiary syphilis depend on the organ system involved.<ref name="pmid10194456">{{cite journal| author=Singh AE, Romanowski B| title=Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 2 | pages= 187-209 | pmid=10194456 | doi= | pmc=88914 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10194456  }} </ref><ref name="pmid21694502">{{cite journal| author=Carlson JA, Dabiri G, Cribier B, Sell S| title=The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. | journal=Am J Dermatopathol | year= 2011 | volume= 33 | issue= 5 | pages= 433-60 | pmid=21694502 | doi=10.1097/DAD.0b013e3181e8b587 | pmc=3690623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694502  }} </ref><ref name="pmid17560432">{{cite journal| author=Wöhrl S, Geusau A| title=Clinical update: syphilis in adults. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1912-4 | pmid=17560432 | doi=10.1016/S0140-6736(07)60895-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560432  }} </ref>


==Physical Examination==
==Physical Examination==
===Primary syphilis: Chancre===
The physical examination findings of syphilis are described according to the stage of syphilis.<ref name="pmid10194456">{{cite journal| author=Singh AE, Romanowski B| title=Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. | journal=Clin Microbiol Rev | year= 1999 | volume= 12 | issue= 2 | pages= 187-209 | pmid=10194456 | doi= | pmc=88914 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10194456  }} </ref><ref name="pmid21694502">{{cite journal| author=Carlson JA, Dabiri G, Cribier B, Sell S| title=The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. | journal=Am J Dermatopathol | year= 2011 | volume= 33 | issue= 5 | pages= 433-60 | pmid=21694502 | doi=10.1097/DAD.0b013e3181e8b587 | pmc=3690623 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21694502  }} </ref><ref name="pmid17560432">{{cite journal| author=Wöhrl S, Geusau A| title=Clinical update: syphilis in adults. | journal=Lancet | year= 2007 | volume= 369 | issue= 9577 | pages= 1912-4 | pmid=17560432 | doi=10.1016/S0140-6736(07)60895-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17560432  }} </ref>
*[[Afebrile]]
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
 
|+
*Chancre:
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Stage of syphilis}}
:*Single painless papule which rapidly progresses an ulcerated, indurated lesion with a surrounding red [[areola]]
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Physical Examination}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Images}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Primary syphilis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
'''Chancre'''
:*Single painless [[papule]] which rapidly progresses to an ulcerated, indurated lesion with a surrounding red [[areola]]
:*Usually located on the [[penis]], [[cervix]], [[labia]], anal canal, [[rectum]], or [[oral cavity]]
:*Usually located on the [[penis]], [[cervix]], [[labia]], anal canal, [[rectum]], or [[oral cavity]]
:*Highly infectious lesion
'''Regional [[lymphadenopathy]]'''
 
*Regional [[lymphadenopathy]] accompanies primary lesion.
:*Onset within a week
:*Unilateral or bilateral
:*Unilateral or bilateral
:*[[Lymph node]]s are firm, painless, non-tender and non-suppurative
:*[[Lymph node]]s are firm, painless, non-tender and non-suppurative
| style="padding: 5px 5px; background: #F5F5F5;" |<gallery>


*Primary [[chancre]] heals spontaneously within 4-6weeks; however, regional lymphadenopathy may persist for longer periods.
File:800px-Primary stage syphilis sore (chancre) on the surface of a tongue-CDC.jpg| Primary stage syphilis sore (chancre) on the surface of a tongue. - By Centers for Disease Control and Prevention (CDC) - http://www.cdc.gov/std/syphilis/images.htm#, Public Domain, https://commons.wikimedia.org/w/index.php?curid=26062941


===Secondary syphilis: Condylomata Lata===
File:800px-Chancres on the penile shaft due to a primary syphilitic infection caused by Treponema pallidum 6803 lores.jpg|Chancres on the penile shaft due to a primary syphilitic infection - By CDC/M. Rein, VD - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #6803.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−, Public Domain, https://commons.wikimedia.org/w/index.php?curid=743113
*Develops 6-8 weeks after the appearance of primary chancre.
</gallery>
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Secondary syphilis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
'''Cardinal signs'''
:*[[Skin rash]]: initial macular lesions on the trunk and proximal limbs with progressive generalized papular rash and may cause necrotic ulcers


*Cardinal signs include:
:*[[Lymphadenopathy]]: localized or generalized, firm and non-tender 
:*Skin rash: initial macular lesions on the trunk and proximal limbs with progressive generalized papular rash and may cause necrotic ulcers.


:*Lymphadenopathy: localized or generalized, firm and non-tender 
'''Condylomata lata'''
 
:*Reddish-brown papular lesions on the intertriginous areas that coalesce and enlarge into large plaques known as condylomata lata  
:*Condylomata lata:
::*Reddish-brown papular lesions on the intertriginous areas that coalesce and enlarge into large plaques known as condylomata lata  
:*Lesions usually progress from painful vesicular pattern to erosive lesions with resultant broad, grey-white highly infectious lesions
:*Lesions usually progress from painful vesicular pattern to erosive lesions with resultant broad, grey-white highly infectious lesions


:*Superficial mucosal patches:
'''Superficial mucosal patches'''
::*Painless
::*Painless
::*May be macular, papular, pustular or mixed
::*May be macular, papular, pustular or mixed.
::*Located on the palate, pharynx, larynx, penis, vulva, anal canal or rectum
::*Located on the [[palate]], [[pharynx]], [[larynx]], [[penis]], [[vulva]], [[anal canal]] or [[rectum]] 
 
| style="padding: 5px 5px; background: #F5F5F5;" |
<gallery>
<gallery perRow="5">
Image:Skin syphillis foot.jpg|Erruption on Sole of Foot Associated with Secondary Syphilis.  
Image:Secondary Syphilis on palms CDC 6809 lores rsh.jpg|Typical presentation of secondary syphilis rash on the palms of the hands and usually also seen on soles of feet - By CDC/ Robert Sumpter - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #6809.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2134272
Image:Skin_syphillis1.jpg|Generalized (Maculo-Papular) Eruption Associated with Secondary Syphilis.
Image:Vaginal syphilis (disturbing image).jpg|Secondary syphilis manifested perineal condylomata lata lesions - De Content Providers(s): CDC - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #4098.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−The direct image URL is [1], Dominio público, https://commons.wikimedia.org/w/index.php?curid=21063
Image:Skin syphillis hand2.jpg|Palmar Erruption Associated with Secondary Syphilis.
Image:Syphilis lesions on back.jpg|Syphilis lesions on a patient's back - By Office of Medical History, US Surgeon General - Adapted from http://history.amedd.army.mil/booksdocs/wwii/internalmedicinevolIII/chapter20figure64.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=1202157
Image:Skin syphillis hand1.jpg|Palmar Erruption Associated with Secondary Syphilis.
Image:Syphilis secondary 15.jpeg|Condymoata lata - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
</gallery>
</gallery>
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Latent syphilis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Asymptomatic (serologically positive)
| style="padding: 5px 5px; background: #F5F5F5;" |
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Tertiary syphilis'''
| style="padding: 5px 5px; background: #F5F5F5;" |
'''Neurosyphilis'''
*Asymptomatic [[meningitis]]
*Symptomatic meningitis: neck stiffness, [[Brudzinski's sign]], [[Kernig's sign]], [[ataxia]].
*Meningovascular syphilis
:*Focal deficits
:*Intermittent or progresses slowly over a few days
*Parenchymatous neurosyphilis
:*Develops 15-20 years after primary infection
:*Presents as [[general paresis]] or [[tabes dorsalis]] with resultant [[ataxia]]
:*[[Argyll Robertson pupil]]: small irregular pupil


===Tertiary syphilis: Gumma===
'''Cardiovascular syphilis'''
*[[Aortic insufficiency physical findings|Aortic regurgitation]]:
:*[[Diastolic murmur]]
:*[[De Musset's sign]]<ref>{{cite journal | author=Sapira JD | title="Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations" | journal=South Med J. | date=1981 Apr | volume=74 | issue=4 | pages=459-67 }}</ref>
'''Gummatous lesions'''
*[[Gumma]]:
*[[Gumma]]:
:*Soft, asymmetric, coalscent [[granuloma|granulomatous]] lesion  
:*Soft, asymmetric, coalscent [[granuloma|granulomatous]] lesion  
:*Solitary lesions less than a centimeter in diameter
:*Solitary lesions less than a centimeter in diameter
:*Appear almost anywhere in the body including in the skeleton
:*Appear almost anywhere in the body  
:*Cutaneous gumma: indurated, nodular, papulosquamous to ulcerative lesions with peripheral hyperpigmentation
:*Cutaneous gumma: indurated, nodular, papulosquamous to ulcerative lesions with peripheral hyperpigmentation
| style="padding: 5px 5px; background: #F5F5F5;" |
<gallery>
File:800px-Gumma of nose due to a long standing tertiary syphilitic Treponema pallidum infection 5330 lores.jpg|A gumma of nose due to a long standing tertiary syphilitic ''Treponema pallidum'' infection. - By CDC/ J. Pledger - This media comes from the Centers for Disease Control and Prevention's Public Health Image Library (PHIL), with identification number #5330.Note: Not all PHIL images are public domain; be sure to check copyright status and credit authors and content providers.English | Slovenščina | +/−, Public Domain, https://commons.wikimedia.org/w/index.php?curid=743277


*Cardiovascular manifestation secondary to aortic dilation with resultant [[Aortic insufficiency physical findings|aortic regurgitation]]:
Image:Syphilis tertiary 01.jpeg| Gummatous lesions in tertiary syphilis - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
:*[[Diastolic murmur]]
Image:Syphilis tertiary 02.jpeg| Gummatous lesions in tertiary syphilis - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
:*[[De Musset's sign]]<ref>{{cite journal | author=Sapira JD | title="Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations" | journal=South Med J. | date=1981 Apr | volume=74 | issue=4 | pages=459-67 }}</ref> a bobbing of the head that de Musset first noted in Parisian prostitutes
 
*Neurological manifestation:
:*Asymptomatic meningitis
::*Asymptomatic neurosyphilis usually has no signs or symptoms and is diagnosed exclusively with the presence of CSF abnormalities notably pleocytosis, elevated protein, decreased glucose or a positive VDRL test.


:*Symptomatic meningitis
Image:Syphilis tertiary 03.jpeg| Gummatous lesions in tertiary syphilis - Adapted from Dermatology Atlas.<ref name="Dermatology Atlas">{{Cite web | title = Dermatology Atlas | url = http://www.atlasdermatologico.com.br/}}</ref>
::*Develops within 6-months to several years of primary infection
</gallery>
::*Typical meningitis symptoms present
|-
::*Cranial nerve abnormalities may be observed
|}
 
:*Meningovascular syphilis
::*Occurs a few months to 10 years (average, 7 years) after the primary infection
::*Associated with [[prodromal]] symptoms lasting weeks to months before focal deficits are identifiable
::*Focal deficits initially are intermittent or progress slowly over a few days
::*Clinical present with CNS vascular insufficiency or [[stroke]] involving the middle cerebral artery
 
:*Parenchymatous neurosyphilis
::*Develops 15-20 years after primary infection
::*Clinical presents as [[general paresis]] or [[tabes dorsalis]] with resultant [[ataxia]]
::*[[Argyll robertson pupil]]: small irregular pupil
 
===Ophthalmic Examination===
*Slit-lamp examination and ophthalmic examination may be helpful to differentiate between acquired and congenital syphilis.
 
*Presence of [[interstitial keratitis]] is suggestive of [[congenital syphilis]] with latent infection of unknown duration.
 
===Clinical pearl: Syphilis detecting Handshake===
{{#ev:youtube|SAedwyzTMWA}}


==References==
==References==
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Latest revision as of 00:23, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aysha Anwar, M.B.B.S[2]; Nate Michalak, B.A.

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Overview

The physical examination findings of syphilis are described according to the stage of syphilis which includes non-tender chancre in primary syphilis followed by rash and generalized lymphadenopathy in secondary syphilis. Physical examination findings in tertiary syphilis depend on the organ system involved.[1][2][3]

Physical Examination

The physical examination findings of syphilis are described according to the stage of syphilis.[1][2][3]

Stage of syphilis Physical Examination Images
Primary syphilis

Chancre

Regional lymphadenopathy

  • Unilateral or bilateral
  • Lymph nodes are firm, painless, non-tender and non-suppurative
Secondary syphilis

Cardinal signs

  • Skin rash: initial macular lesions on the trunk and proximal limbs with progressive generalized papular rash and may cause necrotic ulcers

Condylomata lata

  • Reddish-brown papular lesions on the intertriginous areas that coalesce and enlarge into large plaques known as condylomata lata
  • Lesions usually progress from painful vesicular pattern to erosive lesions with resultant broad, grey-white highly infectious lesions

Superficial mucosal patches

Latent syphilis
  • Asymptomatic (serologically positive)
Tertiary syphilis

Neurosyphilis

  • Focal deficits
  • Intermittent or progresses slowly over a few days
  • Parenchymatous neurosyphilis

Cardiovascular syphilis

Gummatous lesions

  • Soft, asymmetric, coalscent granulomatous lesion
  • Solitary lesions less than a centimeter in diameter
  • Appear almost anywhere in the body
  • Cutaneous gumma: indurated, nodular, papulosquamous to ulcerative lesions with peripheral hyperpigmentation

References

  1. ↑ 1.0 1.1 Singh AE, Romanowski B (1999). "Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features". Clin Microbiol Rev. 12 (2): 187–209. PMC 88914. PMID 10194456.
  2. ↑ 2.0 2.1 Carlson JA, Dabiri G, Cribier B, Sell S (2011). "The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity". Am J Dermatopathol. 33 (5): 433–60. doi:10.1097/DAD.0b013e3181e8b587. PMC 3690623. PMID 21694502.
  3. ↑ 3.0 3.1 Wöhrl S, Geusau A (2007). "Clinical update: syphilis in adults". Lancet. 369 (9577): 1912–4. doi:10.1016/S0140-6736(07)60895-2. PMID 17560432.
  4. ↑ 4.0 4.1 4.2 4.3 "Dermatology Atlas".
  5. ↑ Sapira JD (1981 Apr). ""Quincke, de Musset, Duroziez, and Hill: some aortic regurgitations"". South Med J. 74 (4): 459–67. Check date values in: |date= (help)


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