case report secondary syphylis

ABSTRACT

Back ground : Secondary syphilis usually presents with a cutaneous eruption within 2-10 weeks after the primary chancre and is most florid 3-4 months after infection with variable systemic illness develops. In 10% of patients, highly infectious papules at the mucocutaneous junctions and in moist intertriginous skin, become hypertrophic and dull pink or grey as condylomata lata. Syphilis is caused by Treponema pallidum (ssp. Pallidum), a microaerophilic Spirochete.
Case Report: A case of  secondary syphilis in 21-years-old Javanese boy was reported. He complain about multiple reddish papules, wet, smooth, 1-3cm diameter with oval form on region perianal since 10 weeks but not pain. Papula circular, 2cm in diameter on region back neck. Macular and papular on palm and sole 1cm in diameter, accompanied with slightly fever and malaise. Patient is homosexual and do anal sex before. Dark field was found Spirochetes. VDRL 1:128 and TPHA 1:2560. Initial treatment consisted of penicillin procaine 600.000 U i.m. single dose for 10 days. Laboratory examination was monitored after 1 and 3 months after therapy. Marked healing of the papules and decrease VDRL titer of serology 1:64 in 1 month after therapy and 1:32 in 3 month after therapy.
Discussion : The diagnosis of secondary syphilis was established by clinical history, physical examination, dark field microscopy and serologic test. The orally administered penicillin  have been shown  effective in secondary syphilis. The follow up of patients with physical examination and VDRL titer of serologic examination. 

Key words : secondary syphilis, serologic test, penicillin
 Syphilis is characterized by episodes of active disease (primary, secondary and tertiary stage) interrupted by periods of latency. The cause of syphilis is Treponema pallidum, a motile, corkscrew-shaped, pro karyotic bacterium with a flexible, helically coiled cell wall. Syphilis is transmitted by intimate contact with infectious lesion (most common) or via blood transfusion (if blood collected during early syphilis), also transmitted transplacentally from an infected mother to her fetus. In early part of the twentieth century, 10 percents of population of the United State and Europe was infected with syphilis. Most of this increase has been noted in men, particularly in men who have sex with other men. The incidence of syphilis peaks at age 15-34 years.1,2,3
    The diagnosis is the best established by darkfield microscopy of the serum exudates of the lesion. Serologic identification is possible after the infection has been present for least 3 weeks.3,4
    Primary syphilis occurs within 3 weeks of contact with infected individual, heal within 4-8 weeks, with or without therapy. Secondary syphilis usually presents with a cutaneous eruption within 2-10 weeks after the primary chancre with mild constitutional symptoms.2,3 Patients with secondary syphilis may experience symptomps such as malaise, appetite loss, fever, headache, stiff neck, lacrimation, myalgias, arthralgias, nasal discharge, and depression. Initial lesions are bilaterally symmetric, pale red to pink or pigmented, discrete and round macules.
Macular eruption (roseola syphilitica) consist of 0,5-2,0 cm, pink, discrete, non-scaling, oval macules and patches, which predominantly involve the thrunk and flexor aspects of the upper extremities. Psoriasis syphilitica and frambosia syphilitica, were may also cutaneous manifestation in secondary syphilis. Mucous membrane lesion, enlargement of lymph node, hair (alopecia), ophthalmologic (iritis, uveitis anterior, chorioretinitis), auditory (sensorineural hearing loss, labyrinthitis), nail (onikia, onycholisis), bone (periostitis, osteomyelitis), hematologic (anemia, leukocytosis), renal (acute membranous glomerulonephritis), hepatic (jaundice), gastric (epigastric pain) can manifest in secondary syphilis.
Condylomata lata is other form cutaneous manifestation of secondary syphilis, characterized by flesh-colored, dull pink or grey macerated papules or plaque, their surface may be smooth, papillated, or covered with cauliflower-like vegetations. The common sites are the genital and anal areas and, less frequently, the oral commissures, face, axillae, inframammary fold, and toe webs. Condylomata lata have been reported in 9 percent to 44% of syphilis case.
In acquired syphilis, the organism rapidly penetrates intact mucous membranes or microscopic dermal abrasions within a few hours, enters the lymphatics and blood to produce systemic infection. During the first 5-10 years after the onset of untreated primary infection, the disease principally involves the meninges and blood vessels, resulting in meningovascular neurosyphilis.  The syphilitic infiltrate reflects a delayed-type hypersensitivity response to T. pallidum, and in certain individuals. For example, host humoral and cellular immune responses may prevent the formation of a primary lesion (chancre) on subsequent infections with T pallidum, but they are insufficient to clear the organism. This may be because the outer sheath of the Spirochete is lacking immunogenic molecules, or it may be because of down-regulation of helper T cells of the TH1 class.
Pregnant women treated with penicillin should be monitored for the development of the Jarisch-Herxheimer reaction. This is an acute reaction characterized by fever, malaise, chills, vasodilatation, and hypertension. The onset is within 4-6 hours after administered of penicillin, and it subsides within 24 hours. Jarisch-Herxheimer may have a premature birth of delivery. Patient who are allergic to penicillin may be treated with doxyxycline 100 mg twice daily for 30 days or tetracycline 500mg four times a day for 30 days.2,5,6
Patients with treated primary or secondary syphilis perform quantitative VDRL testing at 1, 3, 6, and 12 months following treatment. If the VDRL titer of 1:8 or more fall at least 4 fold within 12 months or the titer starts to rise, consider more intensive retreatment and examine the Cerebrospinal fluid (CSF). If all clinical and serologic examinations remain satisfactory for 2 years following treatment, the patient can be reassured that cure is complete, and no further follow-up care is needed.
CASE REPORT
    A 21 years old Javanese boy was admitted to Dermatology ward of Dr. Soetomo General Hospital, Surabaya,  on November 30th 2009 with multiple reddish papules on perianal region. Reddish papules on perianal region since 10 weeks but not pain. Firstly 1 papule within few days multiply. There was reddish circular papule on back neck . There was macular papular on palm and sole region, acompanied with slightly fever and malaise since 5 days before hospitalization. He is not yet married. Patient is homosexual and do anal sexual last 17 weeks ago. He ever suffer ulcus on penis before but self healing without any therapy last 14 weeks ago. He complain about enlargement but not pain in both of inguinal. No complain about lesion on oral mucosa. No complain about hairloss.
    General physical examination at first day of admission was an alert. The blood pressure was 120/80 mmHg, pulse rate was 88 times per minute, and body temperature was 37,80C. On head examination , no sign of anemic, cyanotic, icteric and respiratory distress, no hairloss and alopecia. The heart and lungs were normal and  no abnormalities. There was no abnormality on abdominal examination, From extremities there were no edema and warm on palpation, but there were enlargement on both inguinal, not pain.
Examination on  perianal region there were multiple eritemaous papules, wet, 1-3 cm in diameter with oval form. On inguinal region there were enlargement on both. On back neck region there were circular papule, 2cm in diameter. On palm and sole region there were roseola syphilitica 1cm in diameter. On oral mucosa region there were no lesion. 
Clinical manifestation on palm and sole region: roseola syphilitica 1cm in diameter
    The diagnosis based on history, physical examination, dark field microscopy examination and serology.
    Laboratory result revealed hemoglobine concentration 11,0 g/dl, white blood count 80.000/mm3, platelets count 200.000/mm3, Hct 38,2%. Dark field microscopy examination was found spirochetes. Serologic test of VDRL: 1:128 and TPHA: 1:2560. Urine routine examination was normal.
The patient was treated with penicillin procaine G 600.000 U intramuscular once daily for 10 days and there was healing the lesion. Patient’s education include do not do free sex before married and sex safety with condom