Recalcitrant genital papules
This patient was initially told he had genital warts, but the appearance of the lesions, and the presence of a rash on his trunk and extremities, suggested another diagnosis.
Confirm diagnosis with treponemal tests
Syphilis is often a clinical diagnosis with pathologic confirmation. Patients suspected of having syphilis should be screened with nontreponemal tests, such as the Venereal Disease Research Laboratory (VDRL) test or the RPR test, which become positive within 3 weeks of developing primary syphilis.
Diagnosis is confirmed with specific treponemal testing, such as with a fluorescent treponemal antibody absorption assay or the T pallidum particle agglutination test. HIV testing is recommended for all patients with syphilis.
Penicillin G is the mainstay of treatment
Proper selection of penicillin is paramount in the treatment of syphilis. Primary, secondary, and early latent syphilis are treated with an intramuscular injection of 2.4 million units of long-acting benzathine penicillin G. Patients with late latent or latent syphilis of unknown duration are treated with 3 doses of the same injection at weekly intervals, totaling 7.2 million units of benzathine penicillin G.10 Certain penicillin preparations (eg, combinations of benzathine penicillin and procaine penicillin) are not appropriate treatments because they do not provide adequate amounts of the antibiotic.
Watch for this reaction. Approximately 30% of patients following penicillin treatment for spirochete infection develop a Jarisch-Herxheimer reaction (JHR).11 JHR is characterized by an abrupt onset of fever, chills, myalgia, tachycardia, vasodilatation with flushing, exacerbated maculopapular skin rash, or mild hypotension. Care for JHR is generally supportive.
Our patient received an intramuscular injection of 2.4 million units of long-acting benzathine penicillin G. His skin eruption and condylomata lata lesions were completely resolved at follow-up 6 months later.
As recommended by the Centers for Disease Control and Prevention,10 our patient’s RPR titers were repeated at 6 months and again at 12 months to verify a four-fold decline, indicating successful treatment.
CORRESPONDENCE
Anne Bartels, MD, General Medicine, Naval Hospital Camp Lejeune, 100 Brewster Blvd., Camp Lejeune, NC 28547; Anne.k.bartels.mil@mail.mil.
