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Revista médica del Hospital General de México

versión On-line ISSN 2524-177Xversión impresa ISSN 0185-1063

Rev. med. Hosp. Gen. Méx. vol.86 no.3 Ciudad de México jul./sep. 2023  Epub 16-Oct-2023

https://doi.org/10.24875/hgmx.22000086 

Clinical cases

Simultaneous primary and secondary syphilis: a case report in an immunocompetent patient

Ana K. Mendoza-Ibáñez1 

Sofía Beutelspacher1 

Griselda  Montes de Oca1 

Andrés Tirado-Sánchez2  * 

1Department of Dermatology, Hospital General de México “Dr. Eduardo Liceaga”

2Department of Internal Medicine, Hospital General de Zona 30, Instituto Mexicano del Seguro Social. Mexico City, Mexico


Abstract

Syphilis is a systemic infection that develops in different stages with clinical variability and is considered a great mimicker. The clinical stages are differentiated but sometimes occur simultaneously, especially in immunocompromised patients. Simultaneous primary and secondary syphilis (sPSS) is rare in immunocompetent patients, underscoring our present case. We report the case of a 23-year-old male patient, who developed numerous indurated ulcerations on the penile shaft and had extensive papular scaly plaques affecting mainly the palms and soles. Although many cases of sPSS are human immunodeficiency virus related, a high percentage of cases may occur in immunocompetent patients, underscoring the importance of the case presented.

Keywords Immunocompetent individual; Secondary syphilis; Primary syphilis; Treatment

Introduction

Syphilis is an infectious disease caused by the spirochete Treponema pallidum1. It is a systemic disease that affects the skin, adnexa, and mucous membranes. It is transmitted through direct contact with infected mucous membranes during sexual intercourse, most commonly in men who have sex with men (MSM)1,2. The course of the disease is usually classified as early or late syphilis. The first group (early syphilis) includes primary (chancre stage) and secondary (disseminated stage) disease. Late syphilis includes late latent syphilis, latent syphilis of unknown duration, and tertiary syphilis characterized by cardiovascular, neurologic, and gummy lesions.1 In some cases, primary and secondary stages may occur concurrently, which is referred to as simultaneous primary and secondary syphilis (sPSS)3-9. However, it is often associated with immunocompromised (human immunodeficiency virus [HIV]-positive) patients and also affects immunocompetent patients10,11. We report the case of an immunocompetent patient with sPSS and review cases in the literature.

Case report

A 23-year-old man presented with genital ulcers that had been present for four weeks and had been previously treated with a class 1 steroid (clobetasol propionate) for two weeks. Physical examination revealed multiple ulcers with indurated bases involving the penile body (Fig. 1A). He also had multiple erythematous, papular, and scaly plaques on the palms (Fig. 1B) and soles, and bilateral non-painful inguinal lymphadenopathy.

Figure 1 A: multiple indurated penile ulcers. B: palmar manifestation of papulosquamous syphilis. 

Laboratory tests were positive for syphilis (FTA-ABS), and Venereal Disease Research Laboratory (VDRL) tests were reactive and high (VDRL titer 1:320). Serologic testing for HIV and hepatitis was negative. Histologic findings of penile ulceration and palm plaque included ulceration and psoriasiform hyperplasia, respectively, with abundant plasmatic CD79A+ cells. Spirochetes were not found. The patient was treated with a single dose of 2.4 million IU penicillin G benzathine without relapse.

We performed a literature review of cases of sPSS. Of the 24 patients (including the present case), 23 were male and only one was female, with a mean age of 39.6 ± 9.41 years (Table 1). The main risk factors described were multiple sexual partners, unprotected sexual contact, and MSM. Regarding immunological status, 13 (54%) patients were immunocompetent at the time of syphilis diagnosis, which excluded HIV infection; 11 patients were immunosuppressed (45%) and 16 (66%) cases had comorbidities, mainly HIV infection (11 cases, 68%). Most patients were MSM (7 cases, 29%); however, this information was not reported in 8 (33%) cases. Multiple chancres occurred in 9 (37%) patients, and the time of development of sPSS ranged from 3 days to 3 months.

Table 1 Characteristics of cases of primary and secondary syphilis reported in the consulted literature 

Author/References/year Immunologic status Comorbidities Age (Years) Sexual practice Diagnostic tests Primary lesions/Site of lesion Secondary lesions Evolution time Treatment
VDRL Hemagglutination Dark field
Present case IC - 23 HS 1:320 - - M; penis Scaly plaques on palms and soles 1 month PGB 2.4 MIU/IM 3D
Jiamton et al.2, 2018 IC - 23 MSM 1:64 > 1:80 + S; perianal Erythematous papules and macules on palms and soles 3 months PGB 2.4 MIU/IM SD
IC Chlamydia trachomatis infection. 17 HS 1:64 Reactive + M; penis Plaques and papules on trunk, extremities, palms, and soles 1 month PGB 2.4 MIU/IM SD
IS VIH infection. Late syphilis (5 years earlier). 34 BS 1:256 > 1:80 + S; penis Scaly erythematous plaques on palms and soles, CL 2 weeks PGB 2.4 MIU/IM 3D
IS VIH infection. Latent syphilis (1 year earlier). 25 MSM 1:64 > 1:80 + M; penis and scrotum Scaly erythematous plaques on palms and soles 12 days PGB 2.4 MIU/IM SD
IS IV drug user. HIV infection. Previous early syphilis infection. HSV infection 21 MSM 1:256 Reactive + M; penis Erythematous maculopapular plaques on the trunk, palms, and extremities 3 days PGB 2.4 MIU/IM SD
IC HSV infection 37 MSM 1:128 > 1:80 + S; penis Erythematous macules on palms and soles 2 weeks PGB 2.4 MIU/IM SD
IC - 22 HS 1:32 Reactive + M; scrotum Discrete brown plaques on palms and soles 1 month PGB 2.4 MIU/IM
IS HIV infection. Previous latent syphilis (5 years). 24 MSM 1:512 Reactive + S; penis Scaly erythematous plaques on palms/soles. Whitish plaques in the pharynx; CL 1 week PGB 2.4 MIU/IM 3D
Mohanan and Udayashankar3, 2021 IC - 24 HS 1:64 - - S; penis Scaly papules and plaques on palms and soles 3 days PGB 2.4 MIU/IM SD
Nahlia and Setyowatie4, 2020 IS HIV infection. 55 MSM. 1:16 Reactive + M; penis Erythematous macules, alopecia 3 weeks PGB 2.4 MIU/IM SD
Arias-Santiago et al.5, 2011 IC - 54 - - 1:128 - S; penis Erythematous papules on palms 4 days PGB
Sánchez et al.6, 2021 IC Amygdalectomy 28 - 1:32 Reactive - M; extragenital Erythematous macules on the trunk 1 month PGB 2.4 MIU/IM 3D
Morgante et al.7, 2020 IC Tobacco use (TI > 11) 26 - 1:32 - - S; lips Scaly erythematous plaques on palms and soles, papules on legs 2 months PGB 2.4 MIU/IM 3D
Arunprasath et al.8, 2021 IC - 22 - 1:64 Reactive - M; penis Scaly erythematous plaques on the scrotum 10 days PGB 2.4 MIU/IM SD
Cancela and Bengoa9, 2003 IC Cognitive delay. 20 MSM 1:16 - - S; scrotal CL - PGB2.4 MIU/IM 2D
De Sousa10, 2013 IS HIV infection. Antiretroviral treatment 34 - 1:128 - + S; penis Moth-eaten alopecia, erythematous plaques, and papules on arms, palms, and soles 10 weeks PGB 2.4 MIU/IM SD
Pérez-Cortés et al.11, 2014 IS Marijuana user. VIH infection. S. aureus chancre infection. 30 HS 1:64 - + S; penis Scarce erythematous papules on palms and soles 1 month PGB 2.4 MIU/IM 3D
Füeßl12, 2016 IC - 68 - 1:8 - - S; upper lip Scaly plaques on the hands and feet 6 weeks PGB
De Sousa13, 2013 IS HIV infection 30 HS 1:128 - + S; penis Scaly macules and papules on arms, palms and soles 5 weeks PGB 2.4 MIU/IM; SD
Contreras et al.14, 2018 IS HIV infection 36 - Reactive - - S; penis Erythematous maculopapular plaques on the trunk, palms, and soles 1 month PGB 2.4 MIU/IM; SD
Mitra et al.15, 2021 IS HIV infection. Antiretroviral treatment 48 - Negative 1:1024 - S; penis Annular copper-colored plaques on soles 6 weeks PGB 1.2 MIU/IM; 3D
Kutsuna and Fujiya16, 2021 IC - 25 Female sex worker 1:64 1:10240 S; lower lip of the mouth Maculopapular rash on the face 4 weeks Amoxicillin/Probenecid; 14 days
Noviyanthi et al.17, 2022 IS HIV infection. Antiretroviral treatment 35 HS 1:128 Reactive - M; penis Alopecia; plaques with thick scales extremities, trunk, palms, and soles 1 month PGB 2.4 MIU/IM 2D

IC: immunocompetent; IS: immunosuppressed; MSM: men who have sex with men; HS: heterosexual; BS: bisexual; S: single lesion; M: multiple lesions; CL: condylomata lata. PGB: Penicillin G benzathine; MIU/IM: million I.U. intramuscular; SD: single dose; 2D: 2 doses; 3D: 3 doses.

Discussion

sPSS is considered a relatively common disease in immunocompromised patients, associated with HIV infection in at least 25% of cases12. This is due to the alterations in innate and humoral immunity caused by HIV infection, which favor the spread of the pathogen through the bloodstream and promote the rapid appearance of secondary lesions and atypical disease features; these atypical presentations are often observed in patients with high viral loads and low CD4+ T-lymphocyte counts13.

The simultaneous occurrence of primary and secondary lesions in immunocompetent patients is rare but possible14,15. The mechanism by which immunocompetent patients without comorbidities9, as in our case, present simultaneously with chancre and secondary manifestations is not well understood. However, some theories have been proposed. One is that there is a window period for detection of HIV with a negative test but coinfection with both sexually transmitted diseases1,3,4. Another theory is that primary chancre, which consists of a local tissue reaction associated with inoculation, occurs three weeks to 90 days after sexual contact and usually resolves six weeks before secondary manifestations, representing hematogenous dissemination of spirochetes1,5. This rapid dissemination results in secondary features developing before the primary lesion disappears5. Other theories suggest that multiple sexual contacts may cause re-infection without adequate protection or that autoinoculation may be a possible explanation3.

Regardless of immunologic status and clinical presentation, all patients, including our case, were successfully treated with penicillin G benzathine (single or multiple doses) without relapse.

Although sPSS is mainly associated with immunocompromised patients, it is not an exclusive feature and affects immunocompetent patients16,17. At the time of syphilis diagnosis, whether typical or atypical, HIV infection must be excluded because both diseases share the same risk factors. Immunocompetent patients with sPSS and a seronegative result at the time of diagnosis need to be followed up because they may be in a window period1,8. It is essentially an appropriate treatment to prevent relapse and long-term complications.

References

1. O'Byrne P, MacPherson P. Syphilis. BMJ. 2019;365:l4159. [ Links ]

2. Jiamton S, Leeyaphan C, Junsuwan N, Chanyachailert P, Omcharoen V. Concomitant primary and secondary syphilis:a case series from STD Clinic, Siriraj hospital. Siriraj Med J. 2018;70:81-6. [ Links ]

3. Mohanan S, Udayashankar C. Simultaneous primary and secondary syphilis. CosmoDerma. 2021;1:50. [ Links ]

4. Nahlia NL, Setyowatie L. Overlapping primary and secondary syphilis in human immunodeficiency virus (HIV) patient. Qanun Med Med J Faculty Med Muhammadiyah Surabaya. 2020;4:265-72. [ Links ]

5. Arias-Santiago S, O'Valle F, Husein-ElAhmed H, Aneiros-Fernandez J, Sierra Girón-Prieto M. Simultaneous primary and secondary syphilis. J Am Acad Dermatol. 2011;64:AB97. [ Links ]

6. Sánchez-Martini PF, Cantú-Parra L, García-Llaver V, Innocenti-Badano AC, Tennerini ML. Primosecundarismo sifilítico con chancros extragenitales múltiples en un paciente inmunocompetente. Rev Méd Univ FCM Uncuyo. 2021;17:1-7. [ Links ]

7. Morgante MJ, Rivarola E, Badano AC. Coexistence of Primary and Secondary Syphilis Lesions:A Case Report. Facultad de Odontología. Vol. 14. Argentina:Universidad Nacional de Cuyo;2020. 63-6. [ Links ]

8. Arunprasath P, Krishnaswamy M, Rai R. Synchronous primary and secondary syphilis -an uncommon presentation. Indian J Sex Transm Dis AIDS. 2021;42:85-7. [ Links ]

9. Cancela R, Bengoa BE. Primo-secundarismo sifilítico en paciente inmunocompetente. Reporte de un caso. Rev Centro Dermatol Pascua. 2003;12:92-4. [ Links ]

10. De Sousa IC. Simultaneous primary and secondary syphilis associated with syphilitic alopecia and folliculitis in an HIV positive patient. Hair Ther Transplant. 2013;3:1000108. [ Links ]

11. Pérez-Cortés S, Novales-Santa Coloma J, Ramos-Garibay A, Maza-De Franco CA. Syphilitic secundarism in a patient with HIV-Infection. Dermatol Rev Mex. 2014;58:64-70. [ Links ]

12. Füeßl HS. Simultaneous onset of primary and secondary syphilis. MMW Fortschr Med. 2016;158:43. [ Links ]

13. De Sousa IC. Simultaneous primary and secondary syphilis in an HIV-positive patient. J Am Acad Dermatol. 2013;68:AB124. [ Links ]

14. Contreras SN, González-Gómez L, Liguori-Ljoka ME, Sierra-Cadenas V. Sífilis primaria en un secundarismo luético. Med Clin (Barc) 2018;150:e39. [ Links ]

15. Mitra D, Singh GK, Mitra B, Talukdar K, Dhillon A, Singh T. A case of primary and secondary syphilis presenting together as immune reconstitution inflammatory syndrome. Indian J Sex Transm Dis AIDS. 2021;\42:156-8. [ Links ]

16. Kutsuna S, Fujiya Y. Primary and secondary syphilis as chancre of the mouth with rash. Intern Med. 2018;57:155. [ Links ]

17. Noviyanthi RA, Kurniadi I, Iswanty M, Amin S, Adriani A, Muhlis. Overlap of psoriasiform and primary syphilis:an atypical manifestation of secondary syphilis (a case report). Pan Afr Med J. 2022;42:229. [ Links ]

FundingThe authors declare that they have not received any source of funding.

Ethical disclosures

Protection of people and animals. The authors declare that no experiments were carried out on humans or animals for this research.

Data confidentiality. The authors declare that they have followed the protocols of their work center regarding the publication of patient data.

Right to privacy and informed consent. The authors have obtained the informed consent of the patients and/or subjects referred to in the article.

Received: December 27, 2022; Accepted: February 08, 2023

* Correspondence: Andrés Tirado-Sánchez E-mail: atsdermahgm@gmail.com

Conflicts of interest

The authors declare that they have no conflicts of interest.

Creative Commons License Sociedad Médica del Hospital General de Mexico. Published by Permanyer. This is an open ccess article under the CC BY-NC-ND license