What are the signs and symptoms of secondary syphilis?

Signs and Symptoms of Secondary Syphilis

Secondary syphilis typically presents with widespread skin rashes, mucocutaneous lesions, generalized lymphadenopathy, and constitutional symptoms that affect multiple organ systems, occurring approximately 2-8 weeks after the primary infection. 1

Cutaneous Manifestations

• Skin lesions: The most common manifestations are macular, maculopapular, papulosquamous, or pustular skin lesions 1

  • Usually begin on the trunk and spread peripherally
  • Characteristically involve palms and soles
  • Typically non-pruritic
  • Copper-colored appearance (described as "ham-colored") 2
  • May present with circular scaling (Biett's sign) 2

• Condyloma lata: Moist, flat, papular lesions in warm intertrigenous regions (genital, perianal, axillary, and inframammary areas) 1

  • Can resemble human papillomavirus infection
  • Highly infectious

Systemic Symptoms

• Constitutional symptoms: 1, 3

  • Fever
  • Malaise
  • Anorexia
  • Arthralgias
  • Headache

• Lymphadenopathy: Generalized, non-tender enlargement of lymph nodes 1, 3, 4

Mucosal Involvement

• Mucous patches: Painless, gray-white erosions or plaques on oral, pharyngeal, laryngeal, or genital mucosa 3
• Specific angina: Sore throat with mucous patches 4

Neurologic Manifestations

• Acute syphilitic meningitis: Can resemble acute primary HIV infection 1
  • Constitutional symptoms
  • Nonfocal CNS symptoms
  • CSF abnormalities (lymphocytic pleocytosis with mildly elevated CSF protein) 1

Other Organ System Involvement

• Ocular: Uveitis, iritis, or chorioretinitis 1
• Hepatitis: Can present with jaundice (non-viral hepatitis) 1
• Renal: Nephrotic syndrome with edema 1
• Bone/joint: Periostitis and arthritis 3

Clinical Course

• Signs and symptoms of secondary syphilis can persist from a few days to several weeks before resolving spontaneously 1
• The disease then evolves to latent or later stages if untreated 1
• Relapses of secondary syphilis manifestations may occur, most commonly during the first 1-4 years following infection 1, 4

Atypical Presentations

• HIV co-infection may alter the clinical presentation:

  • More apparent clinical lesions
  • Accelerated progression of disease 1
  • More severe manifestations 5
  • Concomitant uveitis and meningitis may be more common 1

• Rare presentations include:

  • Granulomatous inflammation (typically associated with tertiary syphilis but can occur in secondary stage) 6
  • Hyperpigmented dermatosis that can mimic Kaposi's sarcoma in HIV patients 5

Diagnostic Considerations

• Secondary syphilis is often called "The Great Imitator" due to its varied clinical presentations 2, 6
• Diagnosis relies on:
  • Clinical presentation
  • Serologic testing (both nontreponemal and treponemal tests) 1, 3
  • Histopathology when needed (plasma cell infiltrate, endothelial swelling) 2
  • Direct detection methods (darkfield microscopy, direct fluorescent antibody tests) 3

Clinical Pitfalls

• Secondary syphilis may be misdiagnosed due to its protean manifestations
• Always consider syphilis in the differential diagnosis of unexplained rash, especially if palms and soles are involved
• HIV testing should be performed in all patients with syphilis 1
• In HIV-positive patients, atypical presentations are common and may be confused with other HIV-associated conditions 5
• Without treatment, secondary syphilis will resolve spontaneously but progress to latent and potentially tertiary stages with significant morbidity and mortality 4, 7