primary syphylitic chancre can occur anywhere - vulva, penis, hand, tongue etc. The organism just burrows thru a break in the skin or mucosa. for ex. take a look at this image posted by J.C.P. Peper ( thread - http://forum.facmedicine.com/spot-diagnosis/9769-ddx.html ) don't need to mention, how it got there wink) and assuming that the lesion (posted in this challenge) is syphylitic - we have 2 possibilities 1) like i mentioned, it cud be primary syphylitic chancre 2) it could be syphylitic gumma ( note - both the chancre and gumma of syphylis are painless and both cud mimic each other, in both body and mind ). Going by the same token, a patient cud present with a syphylitic gumma on the penis or vulva and it cud be mistaken for a primary chancre ( and if the person gives hx of recent sexual contact, then we will not think beyond primary syphylis...as if the patient had never had sex b4 with infected people ) I am going to emphasize that with an mcq ( it's a very famous USMLE question ) 40 year old female complaines of an indurated painless ulcer on her vulva. Cervical cultures were negative for gonococcus, VDRL postive. LP demonstrated pleiotropy and was VDRL positive. what is dx? A) Chancre B) Condyloma lata C) Gumma D) Condylomata acuminata E) Granuloma Inguinale Answer painless ulcer can be A or C syphilis (chancre or Gumma). However, Pleiotrophy means more than 1 organ injry, so This is 3 syphilis. So : Gumma. now contrast that with this question A 21-year-old sexually active man is notified by the health department that his last sexual contact 3 weeks prior has a positive serologic test for syphilis. He goes to see his physician that day. Which of the following findings in this man is most likely to be indicative of his acquisition of this infection? A Positive VDRL in the CSF B Testicular gumma on biopsy C Mucocutaneous rash D Penile chancre E Genital condyloma lata here the answer is D - penile chancre ( no explanation required ), becos we r assuming that all his previous contacts didn't have syphylis ( they only had AIDS ) Another lesion that can mimic primary syphylitic chancre (in terms of location and appearance) is the chancroid..but youre gonna cry with ducreyi (h. ducreyi) yes cut. leshmeniasis is a valid differential and so is Buruli ulcer and Basal Cell carcinoma I will sum up my argument with an image that says it all....
Some more Self Asessment Questions Question 1 of 3 A 22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Which of the following is true about this patient's condition? A. The causative agent is a virus. B. Light microscopy of fluid from the lesions will reveal gram-negative rods in chains. C. The presence of multiple distinct lesions is uncommon. D. There is a latent phase in which patients are asymptomatic. E. Although associated with persistent symptoms if left untreated, it does not carry a significant risk for mortality. The answer is D. Question 2 of 3 A 22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. The drug of choice for treating this patient works by which of the following mechanisms? A. interfering with protein synthesis at the ribosome B. attaching to sterols in cell membranes C. inhibiting bacterial cell wall synthesis D. inhibiting the transport of amino acids into bacteria E. inhibiting dihydrofolate reductase The answer is C. Question 3 of 3 A 22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Six hours after treating this patient, he calls your office with complaints of new-onset headache, myalgia, and malaise. He also states that he felt feverish immediately prior to calling and measured his temperature, which was 99.8°F. Which of the following is most appropriate at this time? A. Advise transport to the nearest ED for immediate evaluation. B. Advise use of acetaminophen and provide reassurance. C. Advise immediate use of Benadryl and then have the patient go to the nearest ED. D. Start treatment with levaquin. E. Start treatment with oral corticosteroids. The answer is B. EXPLANATION: This patient's presentation is consistent with primary syphilis. Primary syphilis manifests itself usually in the form of solitary or multiple raised, firm papules which eventually erode to form ulcerative craters with raised, indurated margins surrounding the centralized ulcer. These lesions, called chancres, most commonly involve the glans penis in males and the vulva or cervix in females, although they may appear rarely in other areas. Syphilis is caused by the spirochete, T. pallidum, which can be visualized by darkfield microscopy, by silver stain, or by fluorescent antibody microscopy. There is an incubation period of approximately 3 weeks separating the time of initial exposure to T. pallidum and the time of chancre formation. Syphilis is characterized by the presence of latent stages in which there are no signs of clinical disease present. Penicillin is the drug of choice for the treatment of syphilis. In addition to treating patients with diagnosed syphilis, it is recommended that treatment also be administered to all sexual contacts of the past 90 days. It has been demonstrated that up to 30% of asymptomatic sexual contacts of patients with infectious lesions within the past 30 days go on to develop syphilis if left untreated. If left untreated, patients may ultimately develop tertiary syphilis characterized by significant destructive neurologic and cardiovascular symptoms. The mortality rate for untreated tertiary syphilis is approximately 20%. Cephalosporins and penicillin antibiotics act by interfering with the late stages of bacterial cell wall synthesis, although the precise biochemical reactions are not entirely understood. Peptidoglycan provides mechanical stability to the cell wall because of its high degree of cross-linking with alternating amino pyranoside sugar residues (N-acetylglucosamine and N-acetylmuramic acid). The completion of the cross-linking occurs by the action of the enzyme transpeptidase. This transpeptidase reaction, in which the terminal glycine residue of the pentaglycine bridge is joined to the fourth residue of the pentapeptide (D-alanine) thereby releasing the fifth residue (D-alanine), is inhibited by beta-lactams. The patient's symptoms immediately after initiation of treatment are consistent with the Jarisch-Herxheimer reaction. This reaction is characterized by low-grade fever, chills, myalgias, and headache all with an onset within 2”“6 hours of initiation of treatment. Other possible symptoms may include tachycardia, tachypnea, and vasodilation with resultant mild hypotension although these are significantly rarer. The Jarisch-Herxheimer reaction is common (occurring in up to 50% of patients with primary syphilis) and is a self-limiting condition, usually resolving within 12”“24 hours. Symptomatic treatment may be beneficial but no other interventions are necessary.
Well, I certainly wouldn't have said syphilis as my first diagnosis; and cutaneous leishmaniasis is a condition I've never heard about - that's why I love this place - gives me homework! My differentials would have been orf, milker's nodules and (less likely) (broken / infected) herpetic whitlow
