Syphilis physical examination

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

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Physical Examination

The physical exmaination findings of syphilis are described according to the stage of syphilis.

Stage of syphilis	Physical Examination	Images
Primary syphilis	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. Regional lymphadenopathy Unilateral or bilateral Lymph nodes are firm, painless, non-tender and non-suppurative.	Primary stage syphilis sore (chancre) on the surface of a tongue. Chancres on the penile shaft due to a primary syphilitic infection
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. 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. Lesions usually progress from painful vesicular pattern to erosive lesions with resultant broad, grey-white highly infectious lesions. Superficial mucosal patches Painless May be macular, papular, pustular or mixed. Located on the palate, pharynx, larynx, penis, vulva, anal canal or rectum.	Typical presentation of secondary syphilis rash on the palms of the hands and usually also seen on soles of feet Secondary syphilis Syphilis lesions on a patient's back Secondary syphilis
Latent syphilis	ASymptomatic (serologically positive)
Tertiary syphilis	Neurosyphilis ASymptomatic meningitis Symptomatic meningitis: neck stiffness, brudzinski's sign+, kernig's sign+, ataxia. Meningovascular syphilis Focal deficits. Intermittent or progress slowly over a few days. 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. Cardiovascular syphilis aortic regurgitation: Diastolic murmur De Musset's sign Gummatous lesions Gumma: 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.

Primary syphilis: Chancre

• Afebrile

• Chancre:

• Single painless papule which rapidly progresses an ulcerated, indurated lesion with a surrounding red areola.
• Usually located on the penis, cervix, labia, anal canal, rectum, or oral cavity.
• Highly infectious lesion.

• Regional lymphadenopathy accompanies primary lesion.

• Onset within a week.
• Unilateral or bilateral.
• Lymph nodes are firm, painless, non-tender and non-suppurative.

• Primary chancre heals spontaneously within 4-6 weeks; however, regional lymphadenopathy may persist for longer periods.

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  Primary stage syphilis sore (chancre) on the surface of a tongue.

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  Chancres on the penile shaft due to a primary syphilitic infection

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  Primary stage syphilis sore (chancre) on glans (head) of the penis.

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  Syphilis primary chancre.

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  Syphilis primary chancre.

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  Typical presentation of secondary syphilis rash on the palms of the hands and usually also seen on soles of feet

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  Condyoma lata (syphilis secondary)

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  Electron micrograph of Treponema pallidum

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  Syphilis lesions on a patient's back

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  Syphilis lesions on a patient's chest

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  Chancres on the penile shaft due to a primary syphilitic infection

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  Secondary syphilis manifested perineal condylomata lata lesions, which presented as gray, raised papules that sometimes appear on the vulva or near the anus, or in any other warm intertriginous region.

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  Gumma of the nose due to long standing tertiary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

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  Secondary syphilis

Tertiary syphilis: Gumma

• Gumma:

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

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  A gumma of nose due to a long standing tertiary syphilitic Treponema pallidum infection.

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  Tertiary syphilis

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  Tertiary syphilis

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  Tertiary syphilis

• Cardiovascular manifestation secondary to aortic dilation with resultant aortic regurgitation:

• Diastolic murmur
• De Musset's sign 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

• Develops within 6-months to several years of primary infection
• 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

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References

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