Syphilis physical examination

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Physical Examination

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 4-6weeks; however, regional lymphadenopathy may persist for longer periods.

Secondary syphilis: Condylomata Lata

• Develops 6-8 weeks after the appearance of primary chancre.

• Cardinal signs include:

• 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

• 

  Erruption on Sole of Foot Associated with Secondary Syphilis.

• 

  Generalized (Maculo-Papular) Eruption Associated with Secondary Syphilis.

• 

  Palmar Erruption Associated with Secondary Syphilis.

• 

  Palmar Erruption Associated with 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

• 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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