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A 39-year-old woman presents with a nonhealing ulcer over her upper lip for 1 week and a new-onset rash on her trunk (Figures 225-1 and 225-2). The ulcer on her upper lip was misdiagnosed as herpes simplex by another physician. Sexual history revealed that the patient had oral sex with a boyfriend who had a lesion on his penis and she suspected that he had been having sex with other women. The examining physician recognized the nonpainful ulcer and rash as a combination of primary and secondary (P&S) syphilis. An RPR (rapid plasma reagin) was drawn and the patient was treated immediately with IM benzathine penicillin. The RPR came back as 1:128 and the ulcer was healed within 1 week.

FIGURE 225-1

Primary syphilis with a chancre over the lip of a woman. (Reproduced with permission from Richard P. Usatine, MD.)

FIGURE 225-2

A nonpruritic rash of secondary syphilis on the abdomen of the patient shown in Figure 225-1. (Reproduced with permission from Richard P. Usatine, MD.)


Syphilis, caused by Treponema pallidum, is a systemic disease characterized by multiple overlapping stages: primary syphilis (ulcer), secondary syphilis (skin rash, mucocutaneous lesions, or lymphadenopathy), tertiary syphilis (cardiac or gummatous lesions), and early or late latent syphilis (positive serology without clinical manifestations). Neurosyphilis can occur at any stage. Diagnosis is made using treponemal and nontreponemal tests. Treatment is penicillin; the dose and duration depend on the stage.


Lues is another word for syphilis.

Nontreponemal tests:

  • VDRL—Venereal Disease Research Laboratory.

  • RPR—Rapid plasma reagin.

Treponemal tests:

  • EIA—Enzyme immunoassay.

  • TP-PA—T. pallidum particle agglutination.

  • FTA-ABS—Fluorescent treponemal antibody absorption.

  • MHA-TP—Microhemagglutination assay for T. pallidum.


  • In 2015, 23,872 cases of primary and secondary (P&S) syphilis were reported to the Centers for Disease Control and Prevention (CDC), an increase of 19%, reaching a rate of 7.5 cases per 100,000 population.1

  • During 2013–2015, the rate of P&S syphilis increased 18.1% among men (from 11.7 to 13.9 cases per 100,000 men) and 27.3% among women (from 1.1 to 1.4 cases per 100,000 women).1

  • In 2015, the rate of P&S syphilis was highest among persons aged 20–24 years and 25–29 years (20.8 and 23.5 cases per 100,000 population, respectively).1

  • Men who have sex with men (MSM) accounted for 59% of the syphilis cases reported in 2015.1

  • Syphilis rates vary by races/ethnicities. In 2015, the rates among black, Hispanic, and white persons were 21.4, 9.1, and 4.1 cases per 100,000 persons, respectively.1

  • HIV-infected patients were found to have syphilis rates of 62.3 ...

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