The most common manifestation of secondary syphilis is a rash, which includes skin lesions on the palms and soles, with both the rash and a palm lesion evident in this patient at the time of his referral to the infectious disease clinic. The rash is usually maculopapular but can also be pustular or a combination of the two.
Lymphadenopathy, fatigue, fever, and patchy alopecia also occur in patients with secondary syphilis.
Many years (usually decades) after untreated inoculation, tertiary syphilis, the final stage, develops and can lead to devastating neurologic and cardiac sequelae.
Whereas syphilis rates declined between the early 1990s and early 2000s in the United States, cases of syphilis have more recently been increasing among men who have sex with men; infections in this population now comprise more than 70% of all cases of primary and secondary syphilis diagnosed in the United States. Coinfection with HIV is common. Among men who have sex with men, 40% of those who have received a diagnosis of syphilis are also infected with HIV. Our patient underwent HIV testing at the second visit with his primary care physician, who recognized that a persistent sore throat and malaise may be indicative of acute HIV infection. The Centers for Disease Control and Prevention recommends that all men who have sex with men undergo testing for sexually transmitted diseases (HIV infection, gonorrhea, chlamydia, and syphilis) at least annually and that men at high risk (e.g., those with multiple or anonymous sex partners or with a bacterial sexually transmitted disease in the previous 12 months) be tested as frequently as every 3 months.