Syphilis differential diagnosis: Difference between revisions

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* [[Sezary syndrome]]
* [[Sezary syndrome]]
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[[Image:Mycosis_fungoides.JPG|200px|courtesy of wikipedia.org - By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=7139812]]
[[Image:Mycosis_fungoides.JPG|200px|thumb|courtesy of wikipedia.org - By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=7139812]]
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| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pityriasis rosea]]<ref name="pmid27512182">{{cite journal |vauthors=Mahajan K, Relhan V, Relhan AK, Garg VK |title=Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects |journal=Indian J Dermatol |volume=61 |issue=4 |pages=375–84 |year=2016 |pmid=27512182 |pmc=4966395 |doi=10.4103/0019-5154.185699 |url=}}</ref>
| style="background: #DCDCDC; padding: 5px; text-align: center;" |[[Pityriasis rosea]]<ref name="pmid27512182">{{cite journal |vauthors=Mahajan K, Relhan V, Relhan AK, Garg VK |title=Pityriasis Rosea: An Update on Etiopathogenesis and Management of Difficult Aspects |journal=Indian J Dermatol |volume=61 |issue=4 |pages=375–84 |year=2016 |pmid=27512182 |pmc=4966395 |doi=10.4103/0019-5154.185699 |url=}}</ref>
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** [[Biotin]] deficiency
** [[Biotin]] deficiency
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[[Image:Seborrhoeic_dermatitisnew.jpg|200px|By Roymishali - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=27267929]]
[[Image:Seborrhoeic_dermatitisnew.jpg|200px|thumb|By Roymishali - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=27267929]]
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==References==
==References==
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[[Category:Emergency mdicine]]
 
[[Category:Emergency mdicine]]
[[Category:Disease]]
[[Category:Disease]]
[[Category:Primary care]]
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[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]

Latest revision as of 00:23, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2] Aysha Anwar, M.B.B.S[3]

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Overview

Syphilis is named as the "Great Imitator" because the symptomatology and physical exam findings of syphilis in different stages mimicks large variety of other diseases. Syphilis must be differentiated from other common diseases that cause rash such as measles, rubella, Kawasaki disease , and mononucleosis. Syphilis also has overlapping symptoms with the other genital infections such as chancroid, condyloma acuminata, genital warts, herpes simplex, and herpes zoster.[1][2][3][4][5]

Differentiating Syphilis from other Diseases

Syphilis is named as a "great imitator" because symptomatology and physical exam findings of syphilis in different stages mimicks large variety of other diseases.[1][2][3][4][5][6][7][8][9][10][8][11][12][13][14][15][16][17]

Stage of Syphilis Differential diagnosis Findings
Primary Herpes simplex(1,2) Presents as multiple, round, superficial oral and genital ulcers which are painful.[2] Adults with non-typical presentation are more difficult to diagnose. However, prodromal symptoms that occur before the appearance of herpetic lesions helps to differentiate HSV from other conditions with similar symptoms like allergic stomatitis. Genital herpes can be more difficult to diagnose than oral herpes since most genital herpes/HSV-2-infected persons have no classical signs and symptoms.[2]
Granuloma inguinale Commonly characterized as painless, progressive ulcerative lesions without regional lymphadenopathy. The lesions are highly vascular and bleed easily on contact.[3]
Chancroid Characterized by painful sores on the genitalia.[4]
Lymphogranuloma venereum Self-limited genital ulcer or papule with tender inguinal or femoral lymphadenopathy.[5][6]
Condyloma acuminatum Presents as warty lesions in the form of clusters and can be very tiny or can spread into large masses in the genital or penile area.[7][18][19]
Urethritis Discharge (milky or pus-like) from the penis, stinging or burning during urination, itching, tingling, burning or irritation inside the penis.
Cystitis Presents as abnormal urine color (cloudy), blood in the urine, frequent urination or urgent need to urinate, painful or burning urination, pressure in the lower pelvis or back, flank pain, back pain, nausea, vomiting, and chills
Candidiasis Presents as redness, itching and discomfort of affected area.[20][21]
Other STIs Such as Chlamydia, Gonorrhea, and Trichomonas vaginalis
Secondary HIV Acute illness present with fever, lymphadenopathy, rash, fatigue, and myalgia. AIDS classically presents with weight loss, night sweats, fatigue, diarrhea, mucosal sores, cough, and cognitive and neurological deficits.
Pityriasis rosea Pink and flaky oval-shaped rash followed by clusters of smaller, more numerous patches of rash. May be accompanied by headache, fever, nausea and fatigue.
Viral exanthem Such as measles, mumps, chicken pox, cytomegalovirus, coxsackie virus, rubella. Findings may include fever, rash, and constitutional symptoms.[22]
Scarlet fever Presenting symptoms include fever, punctate red macules on the hard and soft palate and uvula (Forchheimer's spots), bright red tongue with a "strawberry" appearance, sore throat and headache and lymphadenopathy.
Insect bite Immediate skin reaction often resulting in a rash and swelling in the injured area, often with formation of vesicles.
Mononucleosis Common symptoms include low-grade fever without chills, sore throat, white patches on tonsils and back of the throat, muscle weakness and sometime extreme fatigue, tender lymphadenopathy, petechial hemorrhage and skin rash.
Rocky mountain spotted fever Symptoms may include maculopapular rash, petechial rash, abdominal pain and joint pain.
Rickettsialpox Overlapping symptoms with secondary syphilis may include flu-like illness including fever, chills, weakness and muscle pain but the most distinctive symptom is the rash that breaks out, spanning the person's entire body.
Kawasaki disease Commonly presents with high and persistent fever, red mucous membranes in mouth, "strawberry tongue", swollen lymph nodes and skin rash in early disease, with peeling off of the skin of the hands, feet and genital area
Yaws Tropical infection of the skin, bones and joints caused by the spirochete bacterium Treponema pertenue
Stevens-Johnson syndrome Symptoms may include fever, sore throat and fatigue. Commonly presents ulcers and other lesions in the mucous membranes, almost always in the mouth and lips but also in the genital and anal regions.
Tertiary Brain tumour Findings which may overlap with neurosyphilis include headache,seizures, visual changes and personality changes.[8]
Other causes of seizures Neurosyphilitic disease can present with seizures and must be differentiated from other causes of seizures.
Other causes of stroke[9] Presents as weakness, sensory loss, gait abnormality and cranial nerve damage.
Meningococcemia Rash, petechiae, headache, confusion, and stiff neck, high fever, mental status changes, nausea and vomiting.[10]
Multiple sclerosis May presents as changes in sensation (hypoesthesia), muscle weakness, abnormal muscle spasms, or difficulty in moving, difficulties with coordination and balance (ataxia), problems in speech (dysarthria) or swallowing (dysphagia), visual problems (nystagmus, optic neuritis, or diplopia), fatigue and acute or chronic pain syndromes, bladder and bowel difficulties, cognitive impairment, or emotional symptomatology (mainly depression).[23]
Other causes of meningitis][8][11] Such as bacterial, fungal and viral meningitis. It commonly presents with headache, nuchal rigidity, fever, petechiae and altered mental status.
Psychosis Presents as hallucinations, delusions, auditory hallucinations, and flat or blunted affect and emotion, poverty of speech (alogia), anhedonia, and lack of motivation.[24]
Vasculitides Cardiovasular syphilis may present as aortitis and aortic aneurysm. Overlapping symptoms with other vasculitis may include back pain, fever, abdominal pain, chest pain, shortness of breath, fatigue, arm and leg weakness, lightheadedness, dizziness, fainting, and headaches.[25][13][14]
Other causes of congestive heart failure Presenting symptoms include dizziness, dyspnea on ordinary exertion or greater shortness of breath with usual activities, fainting, fatigue, hemoptysis or frothy sputum, nocturia or urination during the night, nocturnal cough, orthopnea or sleeping on pillows, palpitations or extra heart beats, paroxysmal nocturnal dyspnea or awakening at night with shortness of breath, shortness of breath, syncope or passing out and weakness.
Other causes of glomerulonephritis May presents as blood in the urine (dark, rust-colored, or brown urine), foamy urine (due to excess protein in the urine), swelling (edema) of the face, eyes, ankles, feet, legs, or abdomen.
Other causes of arthritis Gummatous lesions of syphilis in joints may present as joint pains and stiffness.
Other causes of lymphadenitis May present as fever, myalgia, weight loss, and lymph node enlargement.[15]
Other causes of hepatitis Common presenting symptoms may include dark urine, fatigue, weight loss, fever usually low-grade, itching, jaundice (yellowing of the skin or eyes), loss of appetite, nausea and vomiting.[16]
Other causes of nephrotic syndrome Presents as proteinuria, edema, weight gain, fatigue and dyspnea.
Other causes of uveitis Symptoms of uveitis include eye pain, eye redness, and photophobia. Intermediate, posterior, and panuveitis commonly present with floaters, blurry vision, and impaired vision.[15][17]

Differentiating secondary syphilis from other diseases

  • Secondary siphilis should be differentiated from other diseases causing erythamosquamous rash. the differentials include the following:
Disease Rash Characteristics Signs and Symptoms Associated Conditions Images
Cutaneous T cell lymphoma/Mycosis fungoides[26]
courtesy of wikipedia.org - By Bobjgalindo - Own work, GFDL, https://commons.wikimedia.org/w/index.php?curid=7139812
Pityriasis rosea[27]
  • Pink or salmon in color, which may be scaly; referred to as "herald patch"
  • Oval shape
  • Long axis oriented along the cleavage lines
  • Distributed on the trunk and proximal extremities
  • Squamous marginal collarette and a “fir-tree” or “Christmas tree” distribution on posterior trunk
  • Secondary to viral infections
  • Resolves spontaneously after 6-8 weeks
By James Heilman,MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=16305230
Pityriasis lichenoides chronica
  • Recurrent lesions are usually less evenly scattered than in cases of psoriasis
  • Brownish red or orange-brown in color
  • Lesions are capped by a single detachable, opaque, mica-like scale
  • Often leave hypopigmented macules
courtesy of http://www.regionalderm.com
Nummular dermatitis[30]
  • Lesions commonly relapse after occasional remission or may persist for long periods
  • Pruritus
courtesy of your-doctor.net dermatology atlas
Secondary syphilis[31]
  • Round, coppery, red colored lesions on palms and soles
  • Papules with collarette of scales
Source: https://www.cdc.gov/
Bowen’s disease[32]
  • Erythematous, small, scaly plaque, which enlarges erratically over time
  • Scale is usually yellow or white and it is easily detachable without any bleeding
  • Well-defined margins
By James Heilman, MD - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11509003
Exanthematous pustulosis[34]
Acute generalized exanthematous pustulosis: an unusual side effect of meropenem". Indian J Dermatol 55 (2): 176–7. DOI:10.4103/0019-5154.62759. PMID 20606889. PMC: 2887524., CC BY 1.0, https://commons.wikimedia.org/w/index.php?curid=52979729
Hypertrophic lichen planus[36]

courtesy of wikipedia.org

Sneddon–Wilkinson disease[38]
  • Flaccid pustules that are often generalized and have a tendency to involve the flexural areas
  • Annular configuration
courtesy http://www.atlasdermatologico.com.br/disease.jsf?diseaseId=427
Small plaque parapsoriasis[42]
  • Erythematous plaques with fine scaly surface
  • May present with elongated, finger-like patches
  • Symmetrical distribution on the flanks
  • Known as digitate dermatosis
  • Lesions may be asymptomatic
  • May be mildly pruritic
  • May fade or disappear after sun exposure during the summer season, but typically recur during the winter
courtesy http://www.regionalderm.com
Intertrigo[44]
courtesy of cdc.gov
Langerhans cell histiocytosis[45]
  • Scaling and crusting of scalp
courtesy http://www.regionalderm.com
Tinea manuum/pedum/capitis[49]
  • Scaling, flaking, and sometimes blistering of the affected areas
  • Hair loss with a black dot on scalp in case of tinea capitis
courtesy regionalderm.com
Seborrheic dermatitis
By Roymishali - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=27267929

Syphilitic oral lesions must be differentiated from other diseases causing oral lesions such as leukoplakia and herpes simplex virus infection.

Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Diseases predominantly affecting the oral cavity
Oral Candidiasis
  • Denture users
  • As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for the treatment of lung conditions (e.g, asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.
  • Clinical diagnosis
  • Confirmatory tests rarely needed
Localized candidiasis

Invasive candidasis

Tongue infected with oral candidiasis - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
Herpes simplex oral lesions
  • Stress
  • Recent URTI
  • Female sex
  • The symptoms of primary HSV infection generally resolve within two weeks
Oral herpes simplex infection - By James Heilman, MD - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg
Aphthous ulcers
  • Painful, red spot or bump that develops into an open ulcer
  • Physical examination
  • Diagnosis of exclusion
  • Oral cavity
  • Self-limiting , Pain decreases in 7 to 10 days, with complete healing in 1 to 3 weeks
Apthous ulcer on the lower surface of the tongue - By Ebarruda - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358
Squamous cell carcinoma
Squamous cell carcinoma - By Luca Pastore, Maria Luisa Fiorella, Raffaele Fiorella, Lorenzo Lo Muzio - http://www.plosmedicine.org/article/showImageLarge.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.0050212.g001, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=15252632
Leukoplakia
  • Vulvar lesions occur independent of oral lesions
courtesy of http://www.regionalderm.com
]
Melanoma
Oral melanoma - By Emmanouil K Symvoulakis, Dionysios E Kyrmizakis, Emmanouil I Drivas, Anastassios V Koutsopoulos, Stylianos G Malandrakis, Charalambos E Skoulakis and John G Bizakis - Symvoulakis et al. Head & Face Medicine 2006 2:7 doi:10.1186/1746-160X-2-7 (Open Access), [1], CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=9839811
Fordyce spots
Fordyce spots - Por Perene - Obra do próprio, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19772899
Burning mouth syndrome
Torus palatinus
Torus palatinus - By Photo taken by dozenist, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=846591
Diseases involving oral cavity and other organ systems
Behcet's disease
Behcet's disease - By Ahmet Altiner MD, Rajni Mandal MD - http://dermatology.cdlib.org/1611/articles/18_2009-10-20/2.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17863021
Crohn's disease
Agranulocytosis
Syphilis[54]
oral syphilis - By CDC/Susan Lindsley - http://phil.cdc.gov/phil_images/20021114/34/PHIL_2385_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2134349
Coxsackie virus
  • Symptomatic treatment
Coxsackie virus stomatitis - Adapted from Dermatology Atlas.[55]
Chicken pox
Chickenpox - By James Heilman, MD - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52872565
Measles
  • Unvaccinated individuals[56][57]
  • Crowded and/or unsanitary conditions
  • Traveling to less developed and developing countries
  • Immunocompromized
  • Winter and spring seasons
  • Born after 1956 and never fully vaccinated
  • Health care workers
Koplick spots (Measles) - By CDC - http://phil.cdc.gov/PHIL_Images/20040908/4f54ee8f0e5f49f58aaa30c1bc6413ba/6111_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=824483

Secondary syphilis must be differentiated from other causes of rash and arthritis[58][59][60]

Disease Findings
Nongonococcal septic arthritis
  • Presents with an acute onset of joint swelling and pain (usually monoarticular)
  • Culture of joint fluid reveals organisms
Acute rheumatic fever
  • Presents with polyarthritis and rash (rare presentation) in young adults. Microbiologic or serologic evidence of a recent streptococcal infection confirm the diagnosis.
  • Poststreptococcal arthritis have a rapid response to salicylates or other antiinflammatory drugs.
Syphilis
  • Presents with acute secondary syphilis usually presents with generalized, pustular lesions at the palms and soles with generalized lymphadenopathy
  • Rapid plasma reagin (RPR), Venereal Disease Research Laboratory (VDRL) and Fluorescent treponemal antibody absorption (FTA-ABS) tests confirm the presence of the causative agent.
Reactive arthritis (Reiter syndrome)
  • Musculoskeletal manifestation include arthritis, tenosynovitis, dactylitis, and low back pain.
  • Extraarticular manifestation include conjunctivitis, urethritis, and genital and oral lesions.
  • Reactive arthritis is a clinical diagnosis based upon the pattern of findings and there is no definitive diagnostic test
Hepatitis B virus (HBV) infection
  • Presents with fever, chills, polyarthritis, tenosynovitis, and urticarial rash
  • Synovial fluid analysis usually shows noninflammatory fluid
  • Elevated serum aminotransaminases and evidence of acute HBV infection on serologic testing confirm the presence of the HBV.
Herpes simplex virus (HSV)
  • Genital and extragenital lesions can mimic the skin lesions that occur in disseminated gonococcal infection
  • Viral culture, polymerase chain reaction (PCR), and direct fluorescence antibody confirm the presence of the causative agent.
HIV infection
  • Present with generalized rash with mucus membrane involvement, fever, chills, and arthralgia. Joint effusions are uncommon
Gout and other crystal-induced arthritis
  • Presents with acute monoarthritis with fever and chills
  • Synovial fluid analysis confirm the diagnosis.
Lyme disease
  • Present with erythema chronicum migrans rash and monoarthritis as a later presentation.
  • Clinical characteristics of the rash and and serologic testing confirm the diagnosis.

References

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