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Patient Story

A young woman presents to the office with a total body rash for one week (Figure 181-1). She denies other symptoms and the rash does not itch. Upon examination, tattoos on her hands are visible and she does admit to experimenting with crack and IV heroine. The physician suspects that she may have secondary syphilis and she admits to many sexual partners especially while using drugs. She is given a shot of 2.4 million units of benzathine penicillin IM in the office and her blood is drawn for an RPR and an HIV test. The RPR and HIV tests come back positive along with a treponemal specific confirmatory test. The patient is called to return to the office for some serious counseling and a referral to an infectious disease specialist. The ID specialist is called on the phone to see if he wants to admit her for a lumbar puncture or if he will do this as an outpatient. She needs investigation for neurosyphilis due to her positive HIV status.

FIGURE 181-1

Secondary syphilis in a young woman with a history of injection drug use and multiple sexual partners. Her HIV test was also positive so she was worked up for neurosyphilis. (Used 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.

Synonyms and Acronyms

Lues is another word for syphilis.

Nontreponemal Tests

  • VDRL—Venereal Disease Research Laboratory.

  • RPR—Rapid Plasma Reagin.

Treponemal Tests

  • EIA—Enzyme immunoassay.

  • TPPA—T. pallidum particle agglutination.

  • FTA-ABS—Fluorescent treponemal antibody absorption.

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


  • Primary and secondary (P&S) syphilis cases reported to CDC increased from 11,466 in 2007 to 13,970 in 2011, an increase of 22 percent.1 The rate of P&S syphilis in the US in 2011 (4.5 cases per 100,000 population) was 2.2 percent lower than the rate in 2009 (4.6 cases). This is the first overall decrease in P&S syphilis in 10 years.1

  • The prevalence of P&S syphilis per 100,000 population is extremely low in ages 0 to 4 (0.0), 5 to 9 (0.0), and 10 to 14 (0.1) year olds, with only 25 reported cases in 2011.1

  • The prevalence of P&S syphilis per 100,000 between the ages of 15 and 19 is 3.9, and ...

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