Rash on my penis!!!!!!!!!!!

[unseennude]

A 52-year-old man with no clinically significant medical history presents to the emergency department with a chief complaint of a "rash on my penis." The patient states that the rash first appeared 1 week ago. He denies any pruritus or groin pain in the area of the lesion and denies dysuria and urethral discharge. This is the first time he has had such a rash. He admits to having several recent sexual partners.

On physical examination, his vital signs are normal. The patient has a well-demarcated, ulcerated lesion on ventral aspect of his penis (see Image below). The lesion is not tender to palpation. No other lesions are noted, and no discharge is observed from the urethra. Findings on testicular examination are unremarkable with the exception of bilateral prominent inguinal lymphadenopathy. The remaining physical findings, including cardiac and abdominal findings, are unremarkable.





What is the diagnosis, and what empiric treatment is necessary?
Hint: The lesion is characteristically painless.

[Soul]

Chancre (syphilis), chancroid and scabies are the common causes of ulcer in the penis. Among these chancre is painless.This lesion also looks like a chancre. Moreover he has a h/o multiple sexual contact. So, my diagnosis is Primary Syphilis. Treatment is penicillin G.

[Oak]

I go with Soul

[unseennude]

Dear Soul,
You are absolutely correct about the diagnosis . That man was suffering from Primary Syphillis.


Primary syphilis: Syphilis is an infectious disease caused by the spirochete Treponema pallidum. The disease is usually transmitted by means of sexual contact, and usual routes of transmission are through mucosal ulcerations (eg, genital area, mouth, anus) of an infected partner to the skin or mucous membranes of an uninfected sexual partner.


Primary syphilis manifests as a nonpainful ulcer (chancre) at the site of infection. The lesion is usually on a genital area, but it may also occur on the lips, tongue, cervix, or anus. The lesion usually develops within 3-4 weeks of infection, but it may occur as late as 3 months afterward. This primary lesion spontaneously heals in 3-7 weeks and may go unnoticed, especially if it is on the cervix or anus, and the infected individual may not realize that they have an infection. Unilateral or bilateral regional and painless lymphadenopathy is also a characteristic finding of primary syphilis.

Secondary syphilis is the next phase of the disease and develops 4-10 weeks after the primary lesion appears. This phase is marked by nonspecific systemic complaints, such as fever, headache, fatigue, and lymphadenopathy. A characteristic rash consists of round, discrete, nonpruritic macules on the trunk and proximal extremities, and penny-sized, reddish-brown sores appear on the palms, soles, scalp, and face. These sores may coalesce to form highly infectious lesions called condylomata lata. Symptomatic secondary syphilis also spontaneously resolves, but active episodes may recur from a latent stage during the first 2 years of infection, a period called the early latent phase. The disease then goes into the late latent phase, when patients remain asymptomatic and noninfectious.

About one third of patients with primary syphilis develop a form of the disease called tertiary syphilis, which is a chronic, inflammatory process that takes decades to result in symptoms and physical findings. Cardiovascular syphilis can cause devastating damage to the heart, including aortic endarteritis with medial necrosis and aneurysm formation. Gummatous syphilis manifests as coalescent granulomatous lesions affecting the bones, joints, skin, or almost any part of the body. Finally, symptomatic neurosyphilis can lead to meningitis, brain parenchymal infection, endarteritis, or stroke. Tertiary syphilis can progress over years and decades, causing mental illness, blindness, heart problems, and eventual death.

Standard treatment for primary syphilis or for disease <1 year after exposure is benzathine penicillin G 2.4 million U given by intramuscular (IM) injection. Alternate regimens for patients allergic to penicillin are a 2-week course of doxycycline 100 mg by mouth (PO) twice daily (BID) for 14 days, tetracycline 500 mg PO 4 times daily (QID) for 14 days, or ceftriaxone 1 g given IM or intravenously (IV) once a day for 8-10 days. A recent study also demonstrated efficacy with azithromycin 2 g PO as a single dose.

If the patient was infected for >1 year at the time of presentation, benzathine penicillin G 2.4 million U IM once a week for 3 consecutive weeks or doxycycline for 4 weeks is recommended. Neurosyphilis requires treatment with aqueous crystalline penicillin G 2-4 million U IV every 4 hours for 10-14 days. Patients with neurosyphilis should also be followed up every 6 months for 3-4 years for CSF and serologic testing.

Given this patient's allergy to penicillin and current social situation, he was treated with azithromycin 2 g PO instead of a 14-day course of doxycycline. The ulcerative lesion was swabbed and sent for darkfield microscopy. Rapid plasma reagin (RPR) and Venereal Disease Research Laboratories (VDRL) serum studies were also ordered. A urine sample was sent for Neisseria gonorrhoeae and Chlamydia polymerase chain reaction (PCR), and the patient was counseled about concomitant sexually transmitted diseases (STDs), including HIV. He was referred for HIV testing and given a fast-track follow-up appointment for the laboratory results.

For further information please consult Primary Syphillis under internal medicine or Dermatology and Veneral Disease.