Pigmented macules on hands and feet due to Secondary Syphilis

Introduction

Syphilis is caused by Treponema pallidum. Syphilis in some developing countries still remains a major public health problem, with an estimated 12 million cases occurring Worldwide annually, of which 4 million occur in Africa 1-2.  Resurgence of syphilis has also been reported from European countries with the largest increase seen among men having sex with men (MSM), from 9 cases in 1998 to 40 in 1999 1-2. The rise was attributed to unsafe sex practices due to treatment optimism after the introduction of HAART for HIV infection. In Rotterdam. Syphilis cases have increased dramatically, in 1995-97, with the highest rates reported among CSWs (casual sex workers)³.

A case of secondary syphilis developing from an unprotected sex with male is reported.

Case report

A 24-year old unmarried male came to skin OPD – Sri Devaraj Urs Medical College – Tamaka, Kolar on 26.11.2019 with the history of asymptomatic pigmented lesions over hands and feet in the past 4 months. He was a shy natured person and had guilty feelings. He gave history of having sex with MSM 10 months back, and developed an ulcer on his penis after 2 months. He took treatment from his village doctor with an ointment to apply on the ulcer and few tablets to take. Ulcer healed in 10 days. After 4 months he noticed pigmented lesions over his palms and soles. His friends advised him to get checked up from major hospital; hence he came to our hospital.

On examination, both palms and soles showed pigmented macules of 1X1 cm, which were multiple in number, discrete and asymptomatic (Fig.1). Inner side of the prepuce showed scar of 1X1 cm.

Generalized lymphadenopathy was present. All other systems were normal. Blood VDRL was positive (1:16), and HIV test negative. All other investigations were normal. Injection Benzathine penicillin 24 lakh units, was given intramuscularly after a test dose (12 lakh units on either buttocks). 3 doses of injection were given at weekly interval. Patient started feeling better, skin lesions started regressing (Fig.2). Counseling was done, and was asked to come for follow up.

Discussion

Since 2008 the number of Primary syphilis (Sy 1) and Secondary syphilis (Sy 2) cases has been increasing, and the epidemiology has shifted from heterosexual to gay, bisexual and other men who have sex with men, collectively referred to as MSM⁴. In 2014 the number of reported Sy 1 and Sy 2 cases in the United States was 19999, 3.3 times that of 2000 and the annual rate was 6.3 cases per 100000 population, more than 90% of reported Sy 1 and Sy 2 cases were men and MSM accounted for 83% of male cases where the sex of the partner was known⁵. Among MSM, Syphilis facilitates the transmission of HIV, as it increases the likelihood of transmitting HIV approximately 2-3 folds⁵.

A cross sectional survey of women in the reproductive age group in an urban community in Mumbai in 1995 reported a VDRL seropositivity of 0.5%, while a study from a similar population in Delhi in 1996-2000 showed seropositivity among 4% of cases⁶. Homosexuality is the sexual desire or behavior directed towards a person or persons of one’s own sex. Obtaining the exact prevalence of homosexuality is difficult in India, because of its associated taboo. Sexual behavior studies have classified homosexuals as anything from 1% of sexually active male population to nearly 28% of occasionally homosexual behavior in males⁷. Homosexuals acquire syphilis at a rate 10 times higher than that of heterosexuals⁸. Apart from usual manifestations of syphilis, homosexuals may increasingly suffer from anorectal syphilis. The Sy 2 stage begins 4-12 weeks after the appearance of Sy¹. About 25-35% of the patients who are probably still recovering from the primary chancre begin to show symptoms of Sy 2⁹.

The term “syphilis d’emblee” denotes those cases where primary syphilitic stage is absent, and the patient directly presents with the features of secondary syphilis. It can happen when treponemes have been deeply inoculated as in the case of a puncture wound or during transmission by blood transfusion¹⁰. 

Secondary stage represents the dissemination of the disease involving many organs of the body. Constitutional symptoms may precede or accompany the lesions; the more common symptoms include sore throat, malaise, headache, weight loss, variable fever and musculoskeletal pain¹¹. Cutaneous involvement takes the form of different types of eruptions. Characteristically, these eruptions are 1) non-vesicular, 2) non-pruritic, 3) widespread and bilaterally, symmetrically distributed, but few patients do complain of pruritus, and at times the rash may be confined to only one anatomical area as palms and soles or genitalia. The rash may show polymorphism in the same patient. A good daylight is essential to visualize the rash, which at times may be faint enough to be noticed. If not treated, the rash may persist for many weeks or even months. The rash may become much more intense, after starting the treatment. The eruptions of syphilis can be macular, papular, pustular or a combination of these¹⁰. 

Appearing at about 8-12 weeks macular lesions is the earliest eruption to become noticeable and may be evanescent. The eruption may be pinkish or coppery red, but more frequently it is grayish among Indians. The macules are discrete, nonscaly, round or oval in shape, usually less than one centimeter in size. They are concentrated on trunk, shoulders and flexor aspects of upper arms. Palms and soles are more frequently involved sites, and rash here appears more dramatic in dark skinned individuals, as skin in these areas is lighter. Rash may be sparse and often overlooked by the patient. It may disappear in a few days or evolves into papular rash. Occasionally it may persist as such¹⁰.

Our patient developed asymptomatic macular pigmented rash in both palms and soles after 4 months of the unprotected sex with MSM. He was not bothered to come for treatment, as they were not symptomatic. His friends saw the lesions in the hands, and advised him to consult doctors. Hence, he has come for treatment.

Conclusion

We are reporting this case, because the patient is young earning family member. Desire to experience sex, loneliness and friendship with seducing MSM, he became victim to MSM. When he noticed an ulcer over penis, he took it lightly and took incomplete treatment. When he saw the lesions in palms and soles, again he ignored them, as they were not painful. When his friends insisted to consult the doctors, then only he came for treatment. Today everyone is aware of menace of STDs and HIV/AIDS, when they do unprotected sex with MSM, CSW and unknown people. The youths stay away from their homes, feel lonely, get late marriage, and sex drive make them to become victims of sexually transmitted diseases.