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Year : 1990  |  Volume : 56  |  Issue : 1  |  Page : 37-39

Atypical manifestations of early syphilis

Correspondence Address:
R V Koranne

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A study of 36 untreated patients with early syphilis revealed atypical variations namely; long incubation period of 101 days in I patient, more than 3 chancres in 1, undermined margin of the chancre along with tenderness in 1 and moderate to severe tenderness of the ulcers in 2 cases. In 3 patients there was no indurations of the ulcers. Three patients with primary syphilis had unilateral lymphadenitis, and in I case the lymph nodes were not only tender but showed tendency towardsmatingawell. Insecondarysyphilis, 11 out of 16 patients having condylomata lata had no other muco-cutaneous lesions. Concomitant presence of other venereal disease to account for the atypical manifestations was discounted- by appropriate laboratory tests, response to therapeutic agents and follow up.

Keywords: Early syphilis, Atypical manifestations

How to cite this article:
Koranne R V, Raju P J. Atypical manifestations of early syphilis. Indian J Dermatol Venereol Leprol 1990;56:37-9

How to cite this URL:
Koranne R V, Raju P J. Atypical manifestations of early syphilis. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2020 Sep 26];56:37-9. Available from:

It is easy to diagnose syphilis when the clinical manifestations are typical. Some cases however, may present with atypical features due to various reasons. Appropriate investiga­tions and follow up would help to make the correct diagnosis. We have studied cases having early syphilis to look for atypical manifestations.

  Materials and Methods Top

All the patients having sexually transmitted diseases, during the period between October, 1986 and March, 1987 were investigated to identify the cases having early syphilis. These patients were Subjected y sub to a detailed history, clinical examination, and VDRL test for syphilis. All genital ulcers were subjected to the following investigations : (1) Dark-ground examination was done for the presence of Treponenia pallidum. Aspiration of the enlar­ged lymph nodes was done for DG examination in cases where the patient hae taken local treatment or where the cutaneous lesions did not reveal the organism. (2) Gram staining of the scrape smear was done for Haemophilus ducreyi, and balloon cells and/or giant cells for herpes progenitalis. (3) Giemsa staining of the tissue smear for Donovan bodies. Other causes of genital sores and cutaneous eruptions were also looked for and excluded.

  Results Top

Out of a total of 576 STD patients, early syphilis was detected in 77 cases, giving an incidence of 13.36%. Of these, 36 were untreated cases and were selected for this study. There were 32 males and 4 females. Thirteen (40.62%) male patients were in the age group of 20-24 years, while 1 i (34.37 4/ 4 ) were teenagers (15-19 years). Eleven (30.55%) patients contracted the infection from prostitutes, and 15 (41.66%) others through homosexual exposures. Eleven (30.55%) of these were passive, while 4 (11.11 %) were active homosexuals. Casual sexual contact was incriminated in 6 (16.66%) cases. Of the 4 females, 3 (8.33%) contracted the disease from their husbands, while 1 (2.77%) got the afflic­tion from her friend.

  Clinical manifestations Top

The study group comprised of 10 primary and 26 secondary syphilis patients. The DG examination was positive for  Treponema pallidum Scientific Name Search i> in all the 10 primary syphilis patients and the VDRL titres varied between 1 : 8 - 1 : 64 dilutions. All of them responded to 2.4 mega units of benzathine penicillin within. 14-21 days without any other manifestations.

The precise incubation period could be ascertained in only 4 patients of primary syphilis. Three of these had an incubation period ranging from 10-22 days, while the 4th case had a long incubation period of 101 days. The remaining 6 primary syphilis and 26 secon­dary syphilis cases had had multiple sexual exposures prior to the onset of the lesions, making it difficult to precisely determine the incubation period.

Four patients with primary syphilis had multiple chancres; 2 with 2 ulcers, 1 with 3 ulcers and 1 had 4 ulcers. The ulcers in the last patient were ill-defined, with irregular, undermined margins, and were moderately painful. Two patients with single ulcers had moderate to severe tenderness. Treatment with penicillin relieved the tenderness and the ulcers healed. Three patients had non-indurated chancres.

Inguinal lymph nodes were enlarged in all the 10 cases, but 3 cases had only unilateral lymphadenitis. In one case, the lymph nodes had a tendency towards matting and these were tender as well. Serum proteins and ESR were within the normal limits in this patient and the glandular tenderness disappeared following penicillin.

Twenty six cases had secondary syphilis. Thirteen of these had polymorphic skin lesions. Of these, 4 had maculo-papular syphilides, 5 had papular and papulo-squamous and 4 had papular lesions including condylomata lata lesions. Mucous patches were seen in 7. Further, 5 patients had persisting primary chancres. The remaining 13 patients had only monomorphic lesions, and 11 of these had condylomata lata lesions only [Figure - 1]. One patient had follicular syphilides, distributed on the trunk and the thighs. Moderate itching was the chief presenting complaint in this patient. Further, 1 patient had pustular lesions on the trunk. All the 26 cases of secondary syphilis had enlarged lymph nodes which were firm, rubbery, discrete and non-tender. Nine patients complained of osteocopic pains especially of the long bones of the legs.

T. pallida were demonstrated in 20 cases of secondary syphilis. T. pallida could not be demonstrated from skin lesions as well as from lymph node aspirate in the remaining 6 cases.

Serum VL)RL test was positive in all the 26 cases in titres ranging from 1 : 8 to 1 : 512 dilutions.

  Comments Top

Fifteen (41.66%) patients in the present group contracted the disease through hom(-­sexual exposures. Of these, 10 passive homo­sexuals had condylomata lata lesions around the perianal region and I had condylomata lata lesions in the groin. There was no history of preceding anal chancres in any. Four active homosexuals had had penile chancres in the past.

Recently, there has been an upsurge in the homosexual mode of transmission.[1]

One patient in the present group had an incubation period of 101 days. This patient, although he denied, might have taken some anti­biotics for some other concomitant illness while simultaneously incubating the syphilis.

Intriguing clinical features like multiple non-indurated tender chancres and ulcers with irregular and slightly undermined margins, have already been highlighted by Chapel.[2] Our observations about unilateral lymph adenitis are also in agreement with those of Chapel' who also found it in 18.8% of cases in his series.

In secondary syphilis also, by and large, the manifestations were neither florid, nor genera­lized as mentioned in the older textbook. 3 This observation is further reinforced by the fact that as many as I 1 out of 16 patients with eondylo­mata lata did not have any other muco-cutaneous eruption, implying monomorphic nature of the lesions. Further, Cole et al's observed 3 patients of secondary syphilis with severely pruritic skin lesions. Similar observations of pruritic syphili­des have also been documented by Lochner and Pomeranz[5] and Gupta.[6] One of our patients depicted similar itchy follicular lesions.

  References Top

1.Willcox RR : Changing patterns of treponemal disease, Brit J Vener Dis, 1974; 50 : 169-177.  Back to cited text no. 1    
2.Chapel TA : The variability of syphilitic chancres, Sex Trans Dis, J978; 5 : 68-70.  Back to cited text no. 2    
3.Stokes JH : Modern Clinical Syphilology, 3rd ed, Editors, Stokes JH, Beerman H and Ingraham NR : WB Saunders Company, Philadelphia, 1945.  Back to cited text no. 3    
4.Cole GW, Amon RB and Russell PS : Secondary syphilis presenting as a pruritic dermatosis, Arch Dermatol, 1977; 113 :489-490.  Back to cited text no. 4    
5.Lochner JC and Pomeranz JR : Lichenoid secon­dary syphilis, Arch Dermatol, 1974; 109 : 81-83.  Back to cited text no. 5    
6.Gupta R : Pruritic psoriasiform cutaneous lesions in secondary syphilis, Ind J Dermatol Venereot Leprol, 1988; 54 : 270-271.  Back to cited text no. 6    


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