The palms and soles.

Abstract

QUESTION: A 31-year-old homeless man comes to a free clinic, asking if you can get rid of the spots that have appeared all over his body (figure). He tells you that these spots appeared 3 days ago. The spots are not painful and they do not itch. The patient has no other clinical symptoms and feels generally well. With further questioning, he discusses his use of crack cocaine, which has contributed to his homelessness. A physical examination reveals hyperpigmented macules on the palms, wrists, forearms, soles, and ankles. There is slight scaling on these macules. What additional questions would you like to ask this patient? What other parts of the body would you like to examine? What tests would help you make the diagnosis? What is your differential diagnosis at this point? ANSWER: Taking a sexual history from the patient revealed that he had multiple female sexual partners at the time he was using crack cocaine. Some of the women provided sex for drugs. The genitals and oral mucosa were examined for additional lesions. The patient was found to have mucous patches on the penis and additional macules on the thighs. The patient also had mucous patches in the mouth. The protean manifestations of secondary syphilis generally start 2 to 8 weeks after a chancre is present. In this case, the patient did not remember having a chancre. In secondary syphilis, 90% of patients have skin manifestations, 35% have oral lesions, 20% have genital lesions, and 70% have constitutional symptoms, including fever and malaise.1(p2479) The lesions of secondary syphilis may be macular, maculopapular, papular, pustular, or annular. They are not vesicular. Macules on the palms and soles are highly suggestive of secondary syphilis. The rash is generally not itchy. About 20% of patients have mucous patches or condylomata lata. Lata, or flat, patches occur on the genitals and are flatter than condylomata acuminata. Some patients have moth-eaten alopecia.