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
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Erruption on Sole of Foot Associated with Secondary Syphilis.
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Generalized (Maculo-Papular) Eruption Associated with Secondary Syphilis.
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Palmar Erruption Associated with Secondary Syphilis.
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Palmar Erruption Associated with Secondary Syphilis.
Tertiary syphilis: 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[1] 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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