Evaluation and Diagnosis of Secondary Syphilis in a Middle-Aged Man with Polyarticular Inflammatory Arthritis and Rash
A 46-year-old man presented with arthritis and rash, experiencing episodes of lightheadedness and diaphoresis. His clinical evaluation revealed an elevated erythrocyte sedimentation rate and a rash, eventually leading to a diagnosis of secondary syphilis. This case highlights the importance of considering infectious etiologies in patients with polyarticular inflammatory arthritis and rash, particularly when accompanied by systemic symptoms and a relevant sexual history.
Key Points:
- Patient Presentation: A 46-year-old man presented with arthritis, rash, lightheadedness, and diaphoresis.
- Initial Symptoms: Lightheadedness episodes associated with diaphoresis and mild nausea.
- Emergency Department Evaluation: Normal glucose, electrolytes, kidney-function tests, liver enzymes, complete blood count, and urinalysis. Elevated alkaline phosphatase (157 U/L), erythrocyte sedimentation rate (104 mm/hr), C-reactive protein (6.3 mg/L), and d-dimer (990 ng/mL). Sinus tachycardia observed on ECG. Chest CT showed no pulmonary embolus.
- Rheumatology Clinic Follow-up: History of mild COVID-19, arthritis onset, rash development, alopecia, weight loss, and nasal crusting post-COVID-19. Rash involving chest, back, and legs but sparing palms and soles.
- Medical History and Lifestyle: History of asthma, eczema, cigarette smoking, and alcohol use. Sexually active with men, with the latest sexual activity occurring 5 months prior.
- Physical Examination Findings: Patchy alopecia, nasal crusting, ulcerative lesion at the mouth commissure, swelling, warmth, and mild tenderness of wrists and ankles. Hyperpigmented, macular rash with scaling.
- Differential Diagnosis Considerations:
- Autoimmune and Autoinflammatory Diseases: Psoriatic arthritis, rheumatoid arthritis, systemic lupus erythematosus (SLE), dermatomyositis, systemic vasculitis, VEXAS syndrome.
- Nonrheumatic Diseases: Drug reactions, cancer, infections (tuberculosis, arthritogenic alphaviruses, parvovirus B19, syphilis).
- Diagnosis of Secondary Syphilis:
- Treponemal antibody test and rapid plasma reagin (RPR) test confirmed the diagnosis.
- Secondary syphilis explained polyarthritis, rash, alopecia, nasal, and oral ulceration.
- Management:
- Intramuscular benzathine penicillin G administered.
- Repeat RPR test recommended on the day of treatment to establish a baseline.
- HIV, gonorrhea, and chlamydia testing, followed by HIV preexposure prophylaxis (PrEP) initiated.
- Partner notification and empirical treatment for recent sexual contacts.
- Outcome: Resolution of symptoms post-treatment, with significant improvement in RPR titer.
![](https://hcn.health/wp-content/uploads/2023/08/facts-1-1.png)
According to the Centers for Disease Control and Prevention (CDC), there were more than 76,000 reported cases of syphilis in the US in 2021, marking a 74% increase since 2017. The CDC also reports that men who have sex with men are disproportionately affected, accounting for 36% of all primary and secondary syphilis cases and nearly 47% of all male primary and secondary syphilis cases in 2021. (Yale Medicine)
More on Reproductive & Sexual Health