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==Differentiating Syphilis from other Diseases==
==Differentiating Syphilis from other Diseases==
{| class="wikitable"
! Age
! Site involved
! colspan="1" style="width: 400px;" | Local Examination
|-
| rowspan="6" | Infants
| General Appearance
| colspan="1" style="width: 400px;" | Infants often looks healthy with a good appetite and sleep habits.
|-
| Scalp
| colspan="1" style="width: 400px;" | Fine scaling in mild cases. Thick greasy scales with [[erythema]] in severe cases.<ref>Borda, Luis J., and Tongyu C. Wikramanayake. "Seborrheic Dermatitis and Dandruff: A Comprehensive Review." Journal of clinical and investigative dermatology 3.2 (2015).</ref>Thick greasy scales with erythema in severe cases.
|-
| Face
| colspan="1" | Face may present with scaly salmon colored scales.
|-
| Neck, Axillae and Body Folds
| colspan="1" | Non-scaly moist glistening appearance of lesions which tend to appear confluent.<ref name="pmid4852869">{{cite journal| author=Lewak N| title=Letter: Mythology and SIDS. | journal=N Engl J Med | year= 1974 | volume= 291 | issue= 14 | pages= 740-1 | pmid=4852869 | doi=10.1056/NEJM197410032911423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4852869  }} </ref>
|-
| Trunk
| colspan="1" style="width: 400px;" | Trunk involvement is seen in severe cases. However, the diaper area iscommonly involved which presents with [[erythema]] and maceration of skin with edema of surrounding skin. Secondary bacterial and [[candida|candidal]] infections are common in these cases.<ref name="pmid26051065">{{cite journal| author=Tüzün Y, Wolf R, Bağlam S, Engin B| title=Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis. | journal=Clin Dermatol | year= 2015 | volume= 33 | issue= 4 | pages= 477-82 | pmid=26051065 | doi=10.1016/j.clindermatol.2015.04.012 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26051065  }} </ref>
|-
| Generalized
| colspan="1" style="width: 400px;" | Most commonly seen in Leiner's disease, which is an [[immunosuppressive]] condition. It may involve unusual sites such as extremities and trunk with scaling and [[erythematous]] patches. Scaling and crusting usually spreads to involve other parts of the body with extensive peeling of skin.<ref name="pmid1544726">{{cite journal| author=Fischer HG, Hartmann U, Becker R, Kommans B, Mader A, Hollmann W| title=The excretion of 17-ketosteroids and 17-hydroxycorticosteroids in night urine of elite rowers during altitude training. | journal=Int J Sports Med | year= 1992 | volume= 13 | issue= 1 | pages= 15-20 | pmid=1544726 | doi=10.1055/s-2007-1021227 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1544726  }} </ref><ref name="pmid2958789">{{cite journal| author=Sonea MJ, Moroz BE, Reece ER| title=Leiner's disease associated with diminished third component of complement. | journal=Pediatr Dermatol | year= 1987 | volume= 4 | issue= 2 | pages= 105-7 | pmid=2958789 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2958789  }} </ref><ref name="pmid144462">{{cite journal| author=Evans DI, Holzel A, MacFarlane H| title=Yeast opsonization defect and immunoglobulin deficiency in severe infantile dermatitis (Leiner's disease). | journal=Arch Dis Child | year= 1977 | volume= 52 | issue= 9 | pages= 691-5 | pmid=144462 | doi= | pmc=1544726 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=144462  }} </ref>
|-
| rowspan="5" | Adults
| General appearance
| colspan="1" style="width: 400px;" | Adults may present with a healthy general appearance in mild cases or may present in considerable distress due to widespread involvement especially. Patients may appear ill in cases with underlying diseases associated with seborrheic dermatitis such as [[HIV]], [[malignancy]], or [[parkinsonism]].<ref name="pmid14731170">{{cite journal| author=Dunic I, Vesic S, Jevtovic DJ| title=Oral candidiasis and seborrheic dermatitis in HIV-infected patients on highly active antiretroviral therapy. | journal=HIV Med | year= 2004 | volume= 5 | issue= 1 | pages= 50-4 | pmid=14731170 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14731170  }} </ref>
|-
| Scalp
| colspan="1" style="width: 400px;" | Mild [[desquamation]] to honey coloured crusting of the scalp causing [[alopecia]].
|-
| Face/Retroauricular
areas
| colspan="1" style="width: 400px;" | May present as a "butterfly rash". [[Malar]] erythema and scaling in a symmetrical pattern . Yellowish scaling between eyelashes and eyelids causing [[blepharitis]] with honey colored crusting on free margins.<ref name="pmid3100109">{{cite journal| author=Okochi T, Seike H, Saeki K, Sumikawa K, Yamamoto T, Higashino K| title=A novel alkaline phosphatase isozyme in human adipose tissue. | journal=Clin Chim Acta | year= 1987 | volume= 162 | issue= 1 | pages= 19-27 | pmid=3100109 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3100109  }} </ref>
|-
| Upper Chest
| colspan="1"  style="width: 400px;" | SD presents as petalloid or pityriasiform.
'''Petalloid''': Small reddish  follicular or perifollicular papules that may coalesce forming patches resembling petals of flower.
<br>'''Pityriasiform''': Common on skin tension lines and intertriginous areas and presents as oval scaly [[macules]] and patches. This type involves extensive involvement of the body.<ref name="pmid2936776">{{cite journal| author=Soeprono FF, Schinella RA, Cockerell CJ, Comite SL| title=Seborrheic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study. | journal=J Am Acad Dermatol | year= 1986 | volume= 14 | issue= 2 Pt 1 | pages= 242-8 | pmid=2936776 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2936776  }} </ref>
|-
| Body Folds
| colspan="1" style="width: 400px;" | Lesions usually present as moist, macerated, and [[erythematous]] lesions. May lead to fissuring and secondary infection.<ref name="pmid4852869">{{cite journal| author=Lewak N| title=Letter: Mythology and SIDS. | journal=N Engl J Med | year= 1974 | volume= 291 | issue= 14 | pages= 740-1 | pmid=4852869 | doi=10.1056/NEJM197410032911423 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4852869  }} </ref>
|-
| SD of
Immunosuppression
|
| colspan="1" style="width: 400px;" | It may present as extensive scaling and erythema involving unusual sites such as extremities and is refractory to  treatment. It is usually seen in children and adults with immunosuppression such as [[HIV/AIDS]].<ref>Bukvić, Mokos Z., et al. "Seborrheic dermatitis: an update." Acta dermatovenerologica Croatica: ADC 20.2 (2011): 98-104.</ref><ref>Mathes, Barbara M., and Margaret C. Douglass. "Seborrheic dermatitis in patients with acquired immunodeficiency syndrome." Journal of the American Academy of Dermatology 13.6 (1985): 947-951.</ref>
|}
Syphilis is a curable [[sexually transmitted disease]] caused by the ''[[Treponema pallidum]]'' [[spirochete]]. The route of transmission of syphilis is almost always by [[sexual]] contact, although there are examples of [[congenital syphilis]] via transmission from mother to child [[in utero]]. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Hence, patients with tertiary syphilis should also be tested for other [[STD|sexually transmitted diseases]] such as [[chlamydia]], [[gonorrhea]], [[trichomoniasis]], [[bacterial vaginosis]] and [[HIV|HIV infection]].
Syphilis is a curable [[sexually transmitted disease]] caused by the ''[[Treponema pallidum]]'' [[spirochete]]. The route of transmission of syphilis is almost always by [[sexual]] contact, although there are examples of [[congenital syphilis]] via transmission from mother to child [[in utero]]. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Hence, patients with tertiary syphilis should also be tested for other [[STD|sexually transmitted diseases]] such as [[chlamydia]], [[gonorrhea]], [[trichomoniasis]], [[bacterial vaginosis]] and [[HIV|HIV infection]].
Different [[rash]]-like conditions may be misdiagnosed with [[syphilis]], including:<ref name="MooreSeward2006">{{cite journal|last1=Moore|first1=Zack S|last2=Seward|first2=Jane F|last3=Lane|first3=J Michael|title=Smallpox|journal=The Lancet|volume=367|issue=9508|year=2006|pages=425–435|issn=01406736|doi=10.1016/S0140-6736(06)68143-9}}</ref>
Different [[rash]]-like conditions may be misdiagnosed with [[syphilis]], including:<ref name="MooreSeward2006">{{cite journal|last1=Moore|first1=Zack S|last2=Seward|first2=Jane F|last3=Lane|first3=J Michael|title=Smallpox|journal=The Lancet|volume=367|issue=9508|year=2006|pages=425–435|issn=01406736|doi=10.1016/S0140-6736(06)68143-9}}</ref>

Revision as of 22:06, 22 September 2016

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

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Overview

Syphilis must be differentiated from other common diseases that cause rash such as measles, rubella, Kawasaki disease , and mononucleosis. Syphilis must also be differentiated from other genital infections such as chancroid, Condyloma acuminata, genital warts, Herpes simplex, and Herpes zoster.

Differentiating Syphilis from other Diseases

Age Site involved Local Examination
Infants General Appearance Infants often looks healthy with a good appetite and sleep habits.
Scalp Fine scaling in mild cases. Thick greasy scales with erythema in severe cases.[1]Thick greasy scales with erythema in severe cases.
Face Face may present with scaly salmon colored scales.
Neck, Axillae and Body Folds Non-scaly moist glistening appearance of lesions which tend to appear confluent.[2]
Trunk Trunk involvement is seen in severe cases. However, the diaper area iscommonly involved which presents with erythema and maceration of skin with edema of surrounding skin. Secondary bacterial and candidal infections are common in these cases.[3]
Generalized Most commonly seen in Leiner's disease, which is an immunosuppressive condition. It may involve unusual sites such as extremities and trunk with scaling and erythematous patches. Scaling and crusting usually spreads to involve other parts of the body with extensive peeling of skin.[4][5][6]
Adults General appearance Adults may present with a healthy general appearance in mild cases or may present in considerable distress due to widespread involvement especially. Patients may appear ill in cases with underlying diseases associated with seborrheic dermatitis such as HIV, malignancy, or parkinsonism.[7]
Scalp Mild desquamation to honey coloured crusting of the scalp causing alopecia.
Face/Retroauricular

areas

May present as a "butterfly rash". Malar erythema and scaling in a symmetrical pattern . Yellowish scaling between eyelashes and eyelids causing blepharitis with honey colored crusting on free margins.[8]
Upper Chest SD presents as petalloid or pityriasiform.

Petalloid: Small reddish follicular or perifollicular papules that may coalesce forming patches resembling petals of flower.
Pityriasiform: Common on skin tension lines and intertriginous areas and presents as oval scaly macules and patches. This type involves extensive involvement of the body.[9]

Body Folds Lesions usually present as moist, macerated, and erythematous lesions. May lead to fissuring and secondary infection.[2]
SD of

Immunosuppression

It may present as extensive scaling and erythema involving unusual sites such as extremities and is refractory to treatment. It is usually seen in children and adults with immunosuppression such as HIV/AIDS.[10][11]

Syphilis is a curable sexually transmitted disease caused by the Treponema pallidum spirochete. The route of transmission of syphilis is almost always by sexual contact, although there are examples of congenital syphilis via transmission from mother to child in utero. In fact, the disease was dubbed the "Great Imitator" because it was often confused with other diseases, particularly in its tertiary stage. Hence, patients with tertiary syphilis should also be tested for other sexually transmitted diseases such as chlamydia, gonorrhea, trichomoniasis, bacterial vaginosis and HIV infection. Different rash-like conditions may be misdiagnosed with syphilis, including:[12]

  • Monkeypox - presentation is similar to smallpox, although it is often a milder form, with fever, headache, myalgia, back pain, swollen lymph nodes, a general feeling of discomfort, and exhaustion. Within 1 to 3 days (sometimes longer) after the appearance of fever, the patient develops a papular rash, often first on the face. The lesions usually develop through several stages before crusting and falling off.
  • Coxsackievirus - the most commonly caused disease is the Coxsackie A disease, presenting as hand, foot and mouth disease. It may be asymptomatic or cause mild symptoms, or it may produce fever and painful blisters in the mouth (herpangina), on the palms and fingers of the hand, or on the soles of the feet. There can also be blisters in the throat or above the tonsils. Adults can also be affected. The rash, which can appear several days after high temperature and painful sore throat, can be itchy and painful, especially on the hands/fingers and bottom of feet.
  • Molluscum contagiosum - lesions are commonly flesh-colored, dome-shaped, and pearly in appearance. They are often 1-5 millimeters in diameter, with a dimpled center. Generally not painful, but they may itch or become irritated. Picking or scratching the lesions may lead to further infection or scarring. In about 10% of the cases, eczema develops around the lesions. They may occasionally be complicated by secondary bacterial infections.
  • Parvovirus B19 - the rash of fifth disease is typically described as "slapped cheeks," with erythema across the cheeks and sparing the nasolabial folds, forehead, and mouth.
  • 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. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children. A rash of round lesions about an inch across, may arise on the face, trunk, arms and legs, and soles of the feet, but usually not on the scalp.
  • Varicella-zoster virus - commonly starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7-10 days and clears up within 2-4 weeks.
  • Chickenpox - commonly starts with conjunctival and catarrhal symptoms and then characteristic spots appearing in two or three waves, mainly on the body and head, rather than the hands, becoming itchy raw pox (small open sores which heal mostly without scarring). Touching the fluid from a chickenpox blister can also spread the disease.
  • Impetigo - commonly presents with pimple-like lesions surrounded by erythematous skin. Lesions are pustules, filled with pus, which then break down over 4-6 days and form a thick crust. It's often associated with insect bites, cuts, and other forms of trauma to the skin.
  • Condyloma acuminata - often occur in clusters and can be very tiny or can spread into large masses in the genital or penis area. In women they occur on the outside and inside of the vagina on the opening (cervix) of the uterus, or around the anus. They are approximately as prevalent in men, but the symptoms may be less obvious. When present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum or around the anus. Rarely, genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.
  • Genital warts - often occur in clusters and can be very tiny or can spread into large masses in the genital or penis area. In women they occur on the outside and inside of the vagina on the opening (cervix) of the uterus, or around the anus. They are approximately as prevalent in men, but the symptoms may be less obvious. When present, they usually are seen on the tip of the penis. They also may be found on the shaft of the penis, on the scrotum or around the anus. Rarely, genital warts also can develop in the mouth or throat of a person who has had oral sex with an infected person.
  • Granuloma inguinale - clinically, the disease is commonly characterized as painless, progressive ulcerative lesions without regional lymphadenopathy. The lesions are highly vascular and bleed easily on contact. However, the clinical presentation also can include hypertrophic, necrotic, or sclerotic variants.
  • Herpes simplex - Primary orofacial herpes / Herpes simplex type 1 presents itself as multiple, round, superficial oral ulcers [15] 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.[15]. They present with blisters and ulcers in genital area that are similar to orofacial herpes. Herpes infection can recur even after successful initial treatment. The first episode is usually longer (two to four weeks) more painful and severe than the subsequent/recurrent episodes.
  • Herpes zoster - or shingles usually starts as a painful rash on one side of the face or body. The rash forms blisters that typically scab over in 7–10 days and clears up within 2–4 weeks. Before the rash develops, there is often pain, itching, or tingling in the area where the rash will develop. This may happen anywhere from 1 to 5 days before the rash appears. The pain may be extreme in the affected nerve, where the rash will later develop, and can be characterized as stinging, tingling, aching, numbing, or throbbing, and can be pronounced with quick stabs of intensity. During this phase, herpes zoster is frequently misdiagnosed as other diseases with similar symptoms, including heart attacks and renal colic. Most commonly, the rash occurs in a single stripe around either the left or the right side of the body. In other cases, the rash occurs on one side of the face. In rare cases (usually among people with weakened immune systems), the rash may be more widespread and look similar to a chickenpox rash. Shingles can affect the eye and cause loss of vision.
  • Urethritis - Discharge (milky or pus-like) from the penis, stinging or burning during urination, itching, tingling, burning or irritation inside the penis.

Diseases caused by other species of Treponema

These diseases are caused by other species or subspecies of Treponema:

  • Yaws is a tropical disease characterized by an infection of the skin, bones and joints; it is caused by a spirochete bacterium, Treponema pallidum, sp. pertenue, also called Treponema pertenue
  • Pinta - caused by Treponema carateum
  • Bejel - caused by Treponema endemicum

References

  1. Borda, Luis J., and Tongyu C. Wikramanayake. "Seborrheic Dermatitis and Dandruff: A Comprehensive Review." Journal of clinical and investigative dermatology 3.2 (2015).
  2. 2.0 2.1 Lewak N (1974). "Letter: Mythology and SIDS". N Engl J Med. 291 (14): 740–1. doi:10.1056/NEJM197410032911423. PMID 4852869.
  3. Tüzün Y, Wolf R, Bağlam S, Engin B (2015). "Diaper (napkin) dermatitis: A fold (intertriginous) dermatosis". Clin Dermatol. 33 (4): 477–82. doi:10.1016/j.clindermatol.2015.04.012. PMID 26051065.
  4. Fischer HG, Hartmann U, Becker R, Kommans B, Mader A, Hollmann W (1992). "The excretion of 17-ketosteroids and 17-hydroxycorticosteroids in night urine of elite rowers during altitude training". Int J Sports Med. 13 (1): 15–20. doi:10.1055/s-2007-1021227. PMID 1544726.
  5. Sonea MJ, Moroz BE, Reece ER (1987). "Leiner's disease associated with diminished third component of complement". Pediatr Dermatol. 4 (2): 105–7. PMID 2958789.
  6. Evans DI, Holzel A, MacFarlane H (1977). "Yeast opsonization defect and immunoglobulin deficiency in severe infantile dermatitis (Leiner's disease)". Arch Dis Child. 52 (9): 691–5. PMC 1544726. PMID 144462.
  7. Dunic I, Vesic S, Jevtovic DJ (2004). "Oral candidiasis and seborrheic dermatitis in HIV-infected patients on highly active antiretroviral therapy". HIV Med. 5 (1): 50–4. PMID 14731170.
  8. Okochi T, Seike H, Saeki K, Sumikawa K, Yamamoto T, Higashino K (1987). "A novel alkaline phosphatase isozyme in human adipose tissue". Clin Chim Acta. 162 (1): 19–27. PMID 3100109.
  9. Soeprono FF, Schinella RA, Cockerell CJ, Comite SL (1986). "Seborrheic-like dermatitis of acquired immunodeficiency syndrome. A clinicopathologic study". J Am Acad Dermatol. 14 (2 Pt 1): 242–8. PMID 2936776.
  10. Bukvić, Mokos Z., et al. "Seborrheic dermatitis: an update." Acta dermatovenerologica Croatica: ADC 20.2 (2011): 98-104.
  11. Mathes, Barbara M., and Margaret C. Douglass. "Seborrheic dermatitis in patients with acquired immunodeficiency syndrome." Journal of the American Academy of Dermatology 13.6 (1985): 947-951.
  12. Moore, Zack S; Seward, Jane F; Lane, J Michael (2006). "Smallpox". The Lancet. 367 (9508): 425–435. doi:10.1016/S0140-6736(06)68143-9. ISSN 0140-6736.
  13. Baron, Samuel (1996). Medical microbiology. Galveston, Tex: University of Texas Medical Branch at Galveston. ISBN 0-9631172-1-1.
  14. Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 978-0-443-06839-3.
  15. 15.0 15.1 Fatahzadeh M, Schwartz RA (2007). "Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis, and management". J. Am. Acad. Dermatol. 57 (5): 737–63, quiz 764–6. doi:10.1016/j.jaad.2007.06.027. PMID 17939933.
  16. Workowski, KA.; Berman, S.; Workowski, KA.; Bauer, H.; Bachman, L.; Burstein, G.; Eckert, L.; Geisler, WM.; Ghanem, K. (2010). "Sexually transmitted diseases treatment guidelines, 2010". MMWR Recomm Rep. 59 (RR-12): 1–110. PMID 21160459. Unknown parameter |month= ignored (help)


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