P3.B029: Dermatologic Symptoms as Primary Manifestation of Syphilis: A Case Report

Introduction: Syphilis, an infection caused by Treponema pallidum, has become increasingly prevalent in the United States. With its many stages, there is a wide spectrum of clinical manifestations of the disease. Increased education on the varied presentations of syphilis can improve diagnostic accuracy and enhance identification of subtle cases of sexual abuse.

Case Description: A seven-year-old female with a history of atopic dermatitis, recent nocturnal enuresis and encopresis, and incompletely treated impetigo presented with a worsening, occasionally itchy and painful, perianal and genital rash of one month duration. Review of systems was notable for chronic constipation, fatigue, and intermittent erythematous morbilliform rash on bilateral thighs. History was also notable for unstable housing and five ED visits in the past year. On examination, she was found to have multiple, moist, flat-topped, well demarcated red papules and plaques with overlying white central scale in her perianal region and vulva; diffuse, mobile, nontender, 1-3 cm bilateral lymphadenopathy; and mucous patches on her tongue. Diagnostic workup included wound cultures of lesions, infectious studies including STI testing, and hematology labs. She was discovered to have positive Treponema pallidum antibodies and rapid plasma reagin (RPR) with titers of 1:512. Given her subacute symptom onset and rash consistent with condyloma lata, she was diagnosed with secondary syphilis and treated with 1 dose of intramuscular Penicillin G 50,000 U/kg. Social work and local child protection team were consulted and the case was reported to Child Protective Services (CPS) as soon syphilis and sexual abuse were suspected.

Discussion: This case demonstrates a subtle presentation of syphilis diagnosed primarily based on dermatologic findings. Dermatologic findings associated with syphilis can include the ulcerative chancres of primary syphilis; condyloma lata, mucocutaneous lesions, moth-eaten alopecia, and palmoplantar maculopapular rash of secondary syphilis; and gummas of tertiary syphilis. Syphilis can also present with nonspecific symptoms including fever, lymphadenopathy, or arthralgias or with neurological symptoms as neurosyphilis. It is worth noting that though syphilis is primarily spread congenitally and through direct sexual contact with ulcerative lesions, there are also rare cases of spread through blood products, organ donations, occupational exposures, and nonsexual contact. Additionally, for any child that presents for medical evaluation and especially with concern for STIs, it is important to watch for risk factors for child abuse in the victim and potential perpetrators. In this case, victim-related risk factors included frequent ED visits and a previous history of CPS involvement while parental risk factors included multiple children, significant resource insecurity, history of substance use, and personal history of child abuse.

Conclusion: This case illustrates the subtle and varied presentations of syphilis. Providers should consider a wide differential when evaluating persistent or worsening rashes and be watchful for red flag symptoms concerning for sexual abuse.