A 27 year old patient who presents with maculopapular rash : A Case Report

Ray Anthony A. Camaliga, MD

Family and Community Medicine

PAFP Tacloban Chapter/ EVMC

raycamaliga@gmail.com

09053592933

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 Key words

Maculopapular rash, Syphilis, STI

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 Abstract

Based on the WHO, sexually transmitted infections are a persistent and endemic health

problem in the Philippines. Syphilis is one of the most common STI in the Philippines affecting

ages 15-49 years old. Syphilis can cause serious consequences if left untreated. Awareness

and prevention efforts are crucial in combating the spread of syphilis and other STI. This

includes promoting safe sex practices, increasing access to testing and treatment, and providing

education.

Case Presentation

A 27-year-old male was consulted due to maculopapular nonpruritic rash at the upper

chest of 1 week duration. Rashes spread to the neck, face and upper thighs, this time

associated with body malaise, and undocumented low-grade fever prompting consultation.

Sexual history revealed that he was sexually abused by his uncle at 9 years old. Since then he

became sexually attracted to males and practices oral and anal sex, with 9 male partners that

did not use condoms during sexual encounters.

Physical examination revealed diffuse, maculopapular, well-circumscribed, slightly

erythematous rash in the neck, upper and lower extremities. Four non-tender, ulcerated lesions

were noted at the penile shaft, and bilateral inguinal lymphadenopathy were noted. Diagnosis of

Secondary Syphilis was based on the clinical presentation and as well as the reactive Anti-

Treponemal test. He was treated with Benzathine Penicillin as a single dose only. Safe sex

practices was reiterated and tracing of sexual contacts was done. The patient was advised to

follow up anytime if with concerns and after 6 months thereafter for monitoring.

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Conclusion

As clinicians, we should not forget that we can make a diagnosis based on our thorough

history and complete physical examination alone.

Objectives

1. To present a case of a 27 year old male with a chief complaint of maculopapular rash.

2. To discuss the history and clinical findings which lead to diagnosis of secondary syphilis.

3. To discuss the approach to diagnosis on syphilis and management.

Introduction

Rash is one of the most common reasons for hospital or clinic visit. Most rashes are not

life-threatening but may be a sign of a more serious illness. 1 Approach to diagnosis is usually in
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recognition pattern or morphology and the element of eruption. Further more differential

diagnosis can be narrowed down by history and the clinical features of the patient. 3

Sexually transmitted infections like chlamydia, herpes, HIV and syphilis can be seen with

rashes.15 STI shoud be taken in consideration based on the history and risk factors of the

patient. Syphilis, specifically secondary syphilis affects the skin most often. The patient may

present with nonpruritic macular, maculopapular, or pustular rash, starting at trunk and proximal

extremities .6,16

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Patient information

This is the case of Patient J, M, a 27-year-old male, Born Again Christian, born on

August 14, 1995, in Mindanao and currently residing at Tacloban City, Philippines. Came in with

a chief complaint of rash. 1 week prior to consult, the patient noticed the onset of a raised

nonpruritic well-circumscribed rash at the upper chest, no medications were taken. In the

interim, the rash progressed to the neck and lower limbs, associated with body malaise, and

undocumented low grade fever. Persistence of symptoms prompted consult. The patient was

treated for Gonorrhea in 2019 and underwent HIV screening, revealing a negative result. Had a

family history of hypertension and diabetes on the paternal side. Patient works as a

Non-Organization Fellow teacher, he is a nonsmoker, and nonalcoholic beverage drinker, and

denies any illicit drug use. His sexual debut was at 9 years old, sexually abused by his uncle.

Sexually attracted to males, with 9 sexual partners that don’t use condoms during sexual

encounters, practices oral and anal sex.

Clinical Findings

Vital signs as follows; BP of 100/ 80 mmHg, PR of 79 bpm, RR of 19 cpm, and temp of

36.3 C. Upon examination patient was awake, conscious, and coherent. Skin assessment

revealed a brown skin complexion, with diffuse, maculopapular well-circuscribed, slightly

erythematous rash in the face, neck, upper and lower extremities.( Fig. 1,2). Chest, lungs, heart

and abdomen are unremarkable. Genital and anal exam revealed 4 ulcerated lesions at the

penile shaft, non tender, no visible penile discharge, bilateral inguinal lymphadenopathy, no anal

lesions, non palpable prostate, good anal sphincter tone, no blood per examining finger.

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Figure 1

Figure 2

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 Timeline

Diagnostic Assessment

During the interview, patient was informed about the genital and anal exam and the

patient was hesitant and opted to go home. It was explained to the patient the importance of

physical examination and the reason of doing it. Hence, the patient agreed on the examination.

Based on the salient features of our patient; nonpruritic maculopapular rash, febrile episode,

body malaise, painless penile ulcerations and bilateral inguinal lymphadenopathy , which leads

in consideration of Secondary syphilis. Also in view of the maculopapular rash associated with

episode of fever and based on the patients sexual history, a systemic cause like viral (HIV) and

bacterial infection (disseminated gonorrhea), and an allergic reaction would be the most likely

diagnosis (table 1). Laboratory adjuncts was requested to support the impression and to rule out

other considerations. Since we are considering a sexually transmitted infection; Anti-

treponemal test , HIV and HBsAg was requested. Nucleic acid amplification test was not

requested because gonococcal and chlamydia infection was ruled out. Also, the algorithm in

confirming syphilis infection requires the utilization of serologic test. The traditional algorithm

requires nontreponemal test and if it is positive, a confirmatory treponemal test will be used in

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diagnosis, while the reverse algorithm requires the treponemal test followed by nontreponemal

test. The dilema and the limitation in these case is the unavailability of nontreponemal test

which is part of the algorithm in confirming the diagnosis of syphilis and the fear of the patient

might be lost to follow. This dilema is commonly seen in rural setting and geographically isolated

and disadvantaged community.

Table 1. Differential diagnosis

Rule in Rule out

HIV Maculopapular rash, Cannot be totally ruled out

Nonprupritic,

Body malaise,

Febrile episode,

Painless penile ulceration,

Bilateral inguinal

lymphadenopathy,

9 male sexual partners

Disseminated gonnorhea Maculopapular rash No penile discharge

Febrile episode No polyarthritis

Body malaise

9 male sexual partners

Previous Gonorrhea infection

Allergic reaction Maculopapular rash Nonpruritic

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 Febrile episode

No known allergies

Therapeutic Intervention

Initially the patient was advised to Pinggang Pinoy for adults for his diet. For the

pharmacologic intervention, paracetamol 500mg tab every 4 hours was given if with a

temperature of ≥ 37.8 ℃. Abstinence or use condom if plan to engage in sexual activity.

Retrieved contacts of sexual contacts/ partners were also requested. Referred to the HIV and

AIDS Core Team (HACT) clinic for counseling and testing. Follow-up was advised.

Follow-up and outcomes

Upon follow-up, the patient's diagnostics revealed HIV test was nonreactive, HbsAg was

nonreactive, and Anti- Treponemal test was reactive (29.24). Considering the laboratory finding,

patient was diagnosed as presumptive secondary syphilis The patient was given Benzathine

Penicillin G 2.4MU Deep IM ANST as a single dose only. Reiterated safe sex practices. Patient

was also advised for psychiatric evaluation due to his childhood trauma of being sexually

abused. The patient was advised follow-up anytime if with concerns and 6 months for

monitoring. The Patient was contacted via messenger to determine treatment outcomes (figure

3-4). The patients rashes was resolved, noted healing of penile ulcerations, and no recurrence

of febrile episodes.

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 After 6 months, patient was contacted and reminded on his follow up, as part of

the HIV screening patient was tested again and results revealed to be reactive. Patient is

currently undergoing antiretroviral therapy (ART).

Figure 3

Figure 4

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 Discussion

This case was initially seen by a medical intern with an impression of allergic

reaction. Upon seeing the patient, a complete history and thorough physical examination were

done. A complete medical history and thorough physical examination are critical components in

clinical practice. They provide healthcare providers with important diagnostic information and

help also in establishing a doctor-patient relationship.

Syphilis is a common sexually transmitted infection. It is caused by the spirochete

Treponema pallidum which can be transmitted through sexual contact with infectious lesions of

the mucous membranes or abraded skin, via blood transfusion, or transplacentally from a

pregnant woman to her fetus.

In 2020, WHO estimated 7.1 million adults ages 15-49 years old who acquired syphilis. 4

In the Philippines, in 2022 there are 1,088,342 screening tests done with a reactive test of

20,175 and a reactivity rate of 1.9%. The highest region that screened for syphilis is the National

Capital Region amounting to 510,420 with a reactive test of 10,276. Meanwhile the highest
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reactivity rate with 9.4% is the BARRM. It is seen that homosexual, bisexual and other man

having sex with men (MSM) are high risk of acquiring syphilis.14 Just like in our case with a

history of 9 sexual male partners. These data revealed that syphilis is a current global and

national concern that needs to be given attention.

There are different stages of syphilis. The first stage is primary syphilis, it classically

presents as a solitary, painless ulceration called chancre at the site of inoculation, which

commonly involves the genitals and the anus but it can also be seen in other areas. The mean

incubation period is 21 days but can range from 9-90 days. The primary chancre may go

unnoticed and may heal spontaneously within 3-6 weeks. If left untreated 60% to 90% of this

may progress to secondary stage, 4-8 weeks after the the appearance of the primary lesion.6,7

Secondary syphilis is characterized by generalized mucocutaneous lesion affecting skin and/or

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mucous membranes, often symmetrical and nonpruritic, which was seen in our patient, but

characteristically affects the palm and sole. The rash can vary and mimic other infection and

noninfectious conditions like eczema, psoriasis, tinea versicolor, and alopecia areata, hence
6,8
acquiring the title of “great mimicker”. Rashes may also be associated with body malaise,

fever and lymphadenopathy which was also part of our clinical findings in our patient. Signs and

symptoms may sponatenously resolve and if left untreated it may enter the latent stage. Latent

syphilis is characterized by a positive serology test without signs and symptoms. It is

categorized into two phases, early latent and late latent in which both have different approach in

treatment. Approximately only 25% of these patients can develop into tertiary syphilis. The

manifestations of tertiary syphilis are neurological disease (neurosyphilis), cardiovascular

disease (cardiosyphilis) and gummatous lesions (gumma).

Treponema pallidum is difficult to culture hence for definitive diagnosis of primary and

secondary syphilis is based on the presence of spirochetes in dark-field microscopy.18,20,21

Although dark-field mircroscopy is used for definitive diagnosis it was noted to have high

false-negative readings, and most physicians are not trained to perform these test. It is also not

being offered in private and government hospital in the locality. If not available, the most

commonly used in clinical setting is the serologic test (treponemal and non-treponemal

tests),and it remains to be the method of choice in detecting the presence of syphilis.9 The most

widely used nontreponemal tests are Venereal disease research laboratory (VDRL) and Rapid

Plasma Reagin (RPR),these tests detect IgG and IgM antibodies. Since these antibodies can

occur in other conditions like pregnancy, acute viral infections and autoimmune disorders it may

give a false positive result but most result show only low titres of less than 1:4.6 Based on the

study of Xie et. al., nontreponemanal test has a sensitivity of 77% but a specificity of 100% in

detecting syhilis.22 Therefore due to its high specificity, it is being used to rule in the disease.

Nontreponemal test can be reactive few weeks after inoculation and can often become

nonreactive within a successful treatment.9 Meanwhile treponemal test are highly specific

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because it detect antibodies to antigenic components of T. pallidum, however it cannot

determine if it’s venereal or endemic syphilis.6,9 Based on the study of Park et. al, treponemal

test demonstrated 95-100% sensitivity in detecting new cases of syphilis in all stages

specifically almost 100% sensitive in secondary syphilis, 95.2–100% sensitive in early latent

syphilis, and 86.8–98.5% sensitive in late latent syphilis and a specificity of 100%.14 Treponemal

immunoassays is highly sensitive in detecting secondary and latent stage of syphilis.13, 14 The

treponemal test can became reactive after few weeks after inoculation and even after treatment

hence it cannot be use to determine treatment response, also it cannot determine wheter the

disease is recent or remote, which are its downside.10,11 Therefore treponemal test is primarily

used to confirm result of nontreponemal test.

Different algorithms requires two serologic testing to diagnose syphilis. The traditional

which requires the use of nontreponemal test as initial screening test and reactive samples are

confirmed by a treponemal test while the reverse algorithm which uses treponemal test followed
6,9,10,23
by nontreponemal test. In the Philippines the most used algorithm is the traditional, RPR

specifically because it is easy, can be used on site, and inexpensive.17 In the situation of our

case the nontreponemal test is not available in the institution, as stated by Ortiz et. al, currently

there is no gold standard for the serologic testing of syphilis therefore screening result should

always be correlated with clinical findings in making the diagnosis.23 A presumptive diagnosis

can be made if one of these tests is positive or reactive and if a patients history and clinical

finding strongly suggest of syphilis, even if the serologic test are not reactive, it still

recommended to treat patient as syphilis.11,12,17 Also based on the CDC’s STI treatment

guideline, they recommended treatment in all MSM with signs and symptoms with impression of

primary and secondary syphilis even if without serologic test.19 In our case treponemal test was

the only test done and it revealed a reactive result but clinical findings strongly support the

impression of presumptive secondary syphilis hence supporting the management.

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 In patients diagnosed with syphilis, guideliness from the Centers of Disease Control and

Prevention recommends administration of penicillin G for the treatment of all stages.12 But for

patients who have allergies to penicillin or the availability of medication the WHO guideline

suggest doxycycline 100mg orally twice daily for 14 days or Ceftriaxone 1gm intramascularly

once daily for 10-14 days or in special situation , Azithromycin 2gm once orally. 6 Those who are

received penicillin should be aware of Jarisch-Herxheimer reaction which may present 24 hours

after administration, patient may complaint of fever, chills, headache and muscle pain but may

resolve spontaneously, patients who have reaction should be monitored closely. These

reactions where not noted in our patient. It is also important to tell sexual contacts or partners to

be screened earlier for the disease.13 The importance of these is early detection and treatment

to minimize the spread of the infection.

As primary care physicians we play a vital role in the detection and management of STIs.

We are often the first contact of these patients seeking medical attention for STI related

symptoms or concerns. We should have a high index of suspicion for STI and we should ask

about the sexual history and perform genital and anal examination if warranted. Screening for

STI can also be performed if risk factors and clinical findings are present. Part of our

management is taking a proactive approach by including counseling, safe sex practices, family

planning, and ways to prevent the spread of these infections.

Patient Perspective

The Patient admitted that he was in denial of his diagnosis at first. But at the back of his

mind, he knew that there was a possibility that he could incur another sexually transmitted

infection due to his sexual practice. He is now full with regrets and expressed his realization that

he could have practice safe sex to avoid this illness. His current concern is the denial of his

application to work abroad due to his illness.

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 Informed Consent

Patient gave consent about the discussion and presentation of his case in accordance

that his anonymity and confidentiality will be respected.

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