A 29-year-old man comes to the office due to 2 weeks of malaise and body aches. Initially he attributed these symptoms to a viral infection, but yesterday he noticed a skin rash. He has had no cough, chest pain, shortness of breath, nausea, vomiting, or diarrhea. The patient has no significant past medical history. He drinks alcohol socially, smokes marijuana occasionally, and does not use intravenous drugs. He has been sexually active with 2 women over the past year. The patient recently returned from a ski trip to Vermont.
Temperature is 37.8 C (100 F), blood pressure is 112/68 mm Hg, and pulse is 92/min. A diffuse maculopapular rash is seen on the trunk and extremities, with patchy areas of hair loss on the scalp. Sclerae are anicteric. No oral lesions are present. Rubbery palpable lymph nodes are present in the anterior and posterior cervical areas. No murmurs are heard and the lungs are clear on auscultation. The abdomen is soft and nontender and the spleen is not palpable. The penis is uncircumcised with no lesions, ulcerations, or discharge.
Laboratory results are as follows:
Which of the following is the most likely diagnosis?

Question

A 29-year-old man comes to the office due to 2 weeks of malaise and body aches.  Initially he attributed these symptoms to a viral infection, but yesterday he noticed a skin rash.  He has had no cough, chest pain, shortness of breath, nausea, vomiting, or diarrhea.  The patient has no significant past medical history.  He drinks alcohol socially, smokes marijuana occasionally, and does not use intravenous drugs.  He has been sexually active with 2 women over the past year.  The patient recently returned from a ski trip to Vermont.
Temperature is 37.8 C (100 F), blood pressure is 112/68 mm Hg, and pulse is 92/min.  A diffuse maculopapular rash is seen on the trunk and extremities, with patchy areas of hair loss on the scalp.  Sclerae are anicteric.  No oral lesions are present.  Rubbery palpable lymph nodes are present in the anterior and posterior cervical areas.  No murmurs are heard and the lungs are clear on auscultation.  The abdomen is soft and nontender and the spleen is not palpable.  The penis is uncircumcised with no lesions, ulcerations, or discharge.
Laboratory results are as follows:
 Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient has a diffuse maculopapular rash on the trunk and extremities, patchy hair loss, cervical lymphadenopathy, and mild hepatitis. In a sexually active patient, this presentation is highly suggestive of secondary syphilis. Approximately 25% of patients with untreated primary syphilis progress to secondary syphilis within weeks or a few months. Often these patients did not notice the chancre of primary syphilis and have no history of a genital lesion. Secondary syphilis is associated with the following manifestations: Systemic symptoms (eg, fever, malaise, headache, anorexia, diffuse lymphadenopathy)Maculopapular rash involving the entire trunk and extremities (including palms and soles)Condyloma latum (painless wartlike lesions)Generalized lymphadenopathy (enlarged epitrochlear nodes are characteristic)"Moth-eaten" alopeciaDiffuse organ involvement (eg, mild hepatitis, uveitis, meningitis) Systemic symptoms (eg, fever, malaise, headache, anorexia, diffuse lymphadenopathy) Maculopapular rash involving the entire trunk and extremities (including palms and soles) Maculopapular rash Condyloma latum (painless wartlike lesions) Generalized lymphadenopathy (enlarged epitrochlear nodes are characteristic) "Moth-eaten" alopecia "Moth-eaten" alopecia Diffuse organ involvement (eg, mild hepatitis, uveitis, meningitis) The liver manifestations of secondary syphilis generally include a high serum alkaline phosphatase with normal or mildly elevated transaminases. Serologic testing in secondary syphilis is nearly always positive. Diagnosis is established by a positive VDRL or rapid plasma reagin test and confirmed by a treponemal-specific test (eg, FTA-ABS). Treatment consists of a single dose of intramuscular, long-acting penicillin. (Choice A) Erythema multiforme is a target-shaped lesion that is associated with herpes simplex virus infection. Lesions most commonly occur on the extensor surfaces of the extremities (particularly the hands and feet). Erythema multiforme (Choice B) Chronic hepatitis B virus can be associated with extrahepatic manifestations (eg, polyarteritis nodosa, membranous nephropathy) in 10-20% of cases. Although palpable purpura can occur, maculopapular rash is rare. (Choice C) Infectious mononucleosis can cause malaise, myalgia, and generalized rash (eg, maculopapular, urticarial, petechial). However, rash is most common after the administration of amoxicillin. In addition, patients usually also have fever, pharyngitis, lymphadenopathy, and atypical lymphocytosis. Alopecia would be atypical. (Choice D) Rocky Mountain spotted fever is a tick-borne illness that usually presents with systemic symptoms followed several days later by a macular, petechial rash. This disease does not generally cause alopecia or significant lymphadenopathy. Educational objective: Secondary syphilis can produce a wide variety of manifestations including diffuse maculopapular rash (most characteristic), systemic symptoms (eg, fever, malaise, headache, anorexia, diffuse lymphadenopathy), and diffuse organ involvement (eg, mild hepatitis, uveitis). Diagnosis is confirmed with serologic testing using nontreponemal (eg, rapid plasma reagin, VDRL) and treponemal (eg, FTA-ABS) assays. __________ References: Syphilis: a reemerging infection. (http://www.ncbi.nlm.nih.gov/pubmed/22963062) The rash of secondary syphilis. (http://www.ncbi.nlm.nih.gov/pubmed/17200385)

A 29-Year-Old Man Comes to the Office Due to 2