Secondary Syphilis

Aka: Secondary Syphilis, Condyloma Lata, Condyloma Latum, Syphilitic Alopecia, Lues Maligna, Ulceronodular Syphilis, Malignant Syphilis

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II. Pathophysiology

  1. Secondary Syphilis represents the bacteremic stage of Syphilis (replication and systemic spread)
  2. Contrast with the localized disease (Chancre) in Primary Syphilis

III. Course

  1. Begins 6 to 8 weeks (as early as 2 weeks) following onset of Chancre (Primary Syphilis)
  2. Follows 3-6 weeks asymptomatic period after Chancre resolves but before Secondary Syphilis manifestations
  3. Resolves spontaneously in weeks to months without treatment

IV. Symptoms: Nonspecific

  1. Malaise
  2. Fatigue
  3. Headache
  4. Fever
  5. Pharyngitis
  6. Arthralgia
  7. Myalgia
  8. Lymphadenopathy
  9. Hepatosplenomegaly
  10. Unintentional Weight Loss

V. Signs

  1. Highly infectious lesions can occur on mucus membrane
  2. Generalized Lymphadenopathy
  3. Papulosquamous Dermatosis
    1. Painless maculopapular rash starting on face and trunk (and spreading to palms and soles)
    2. Resolves over a 6 week course
    3. Characteristics
      1. Pale, pink to red discrete round Macular to papular lesions
      2. Scaling over surface
    4. Size: "Nickels and Dimes"
      1. Papules <1cm (Dimes): Usually 5-10 mm
      2. Plaques >1cm (Nickels)
    5. Distribution
      1. Starts on face, trunk and flexor extremity surfaces (may be absent, with only palm and sole lesions)
      2. Progresses to involve symmetric lesions on palms and soles
    6. Differential Diagnosis
      1. Pityriasis Rosea
      2. Psoriasis
      3. Drug Eruption
      4. Viral Exanthem
      5. Scarlet Fever
  4. Condyloma Lata
    1. Painless, wart-like lesions
    2. Like the Papulosquamous Dermatosis, resolves over a 6 week course
    3. Papules coalesce, macerate and may form flat, moist, ulcerated lesions
      1. Highly infectious (teaming with Spirochetes)
    4. Become large, flat highly contagious lesions
      1. Involves moist areas
      2. Involves mouth, genitalia and intertriginous areas (perineum, axilla, between toes)
  5. Syphilitic Alopecia (up to 12% of Secondary Syphilis cases)
    1. Alopecia with patchy, moth-eaten appearance
    2. Eyebrows may also be lost

VI. Complications

  1. Lues Maligna (Ulceronodular Syphilis, Malignant Syphilis)
    1. Severe form of Secondary Syphilis (especially in immunosuppressed patients)
  2. Hepatitis
  3. Periostitis
  4. Nephropathy or Nephrotic Syndrome
  5. Uveitis or Iritis

VII. Labs

  1. See Syphilis Testing
    1. Diagnostic blood testing is typically positive in Secondary Syphilis
  2. Dark field microscopy
    1. Indicated in Condyloma Lata and other skin lesions with direct pathogen infiltration
    2. Treponemes will be visible
  3. Other associated lab findings
    1. Serum transaminase elevations may occur (hepatitis)
    2. Urinalysis with Proteinuria (in Nephrotic Syndrome)

VIII. Management

  1. See Syphilis
  2. See Neurosyphilis

IX. References

  1. Green, Cohen, Billington (2016) Crit Dec Emerg Med 30(11): 4-10
  2. Kirk, McHugh and Parnell (2023) Crit Dec Emerg Med 37(8): 23-9
  3. Mattel (2012) Am Fam Physician 86(5): 433-40 [PubMed]
  4. Ricco (2020) Am Fam Physician 102(2): 91-8 [PubMed]

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