Clinical Image Open Access
Syphilis Primaria Seropositiva : A "Clinical Chameleon:"?
Bakardzhiev I1, Pehlivanov G2, Chokoeva AA3, Tchernev G4*
1Medical College, Medical University of Varna. Tsar Osvoboditel 84, Bulgaria
2Department of Dermatology and Venereology Faculty of Medicine, Medical University of Sofia, Bulgaria
3Onkoderma-Policlinic for Dermatology and Dermatologic Surgery, General Skobelev, Sofia, Bulgaria
4Policlinic for Dermatology and Venereology, University Hospital Lozenetz, Sofia, Bulgaria
*Corresponding author: Assoc. Prof. Georgi Tchernev, Policlinic for Dermatology and Venereology, University Hospital Lozenetz, Koziak street 1, 1407 Sofia, Bulgaria, Tel: +359 885 588 424; E-mail: @
Received: March 17, 2016; Accepted: March 20, 2016; Published: March 23, 2016.
Citation: Bakardzhiev I, Pehlivanov G, Chokoeva AA, Tchernev G (2016) Syphilis Primaria Seropositiva : A "Clinical Chameleon"? Clin Res Dermatol Open Access 3(1): 1-2. DOI:
We report about a 47-year-old male patient presented to the policlinic of dermatology of the University Hospital with complaints of a multiple painless erosive lesions, located at the inguinal area, with duration approximately 1-1.5 months. Initially, a single painless, sharply demarcated erosive lesion with tendency to spontaneous recovery occurred in the suprapubic area, right above the base of the penis. Two similar lesion occurred 2 weeks later, located distally and medially from the first one lesion (Figure 1a, 1b). The patient reported repeated and indiscriminate casual unprotected heterosexual contacts. No other complaints, neither additional history were reported.

Within the dermatologic examination, an oval erythematous ulceration, with shiny surface and sharply demarcated edges, slightly elevated above the healthy tissue was observed on the dorsal surface of the base of the penis, measuring approximately 13 mm. Two similar satellite ulcerations were also established, localized in the suprapubic area, each of them in different stage of epithelisation, with evidence spontaneous recovery. No other pathological changes were found on the other sides of the body, neither in the hair, nails and mucosal membranes. Enlarged, but painless lymph nodes were detected on palpation in the inguinal fold. Serological screening established positive VDRL and TPHA tests, while HIV rapid test, as well as the hepatitis B, C markers were negative.
Figure 1a, 1b: Sharply demarcated erosive lesions with tendency to spontaneous recovery in the suprapubic area, right above the base of the penis where also a nother fresh double conturated lesion could be observed.
Diagnosis of multiple primary affects within fresh syphilitic infection was made, based on the clinical findings and laboratory tests. Intramuscular injections of benzathine penicillin G ( two injections in 4-week intervals at a dose of 2.4×106 IU) led to complete resolution of the lesions within 3 months and to substantially decreased titers on laboratory tests.

Multiple ulceration as well as primary affects with extragenital location are generally considered as unusual manifestation and do not belong to the standard clinical features of patients in the first stage of syphilis [1, 2]. That is why the diagnosis is often overlooked, the therapy is inadequate, while the ulcerations showing high tendency for self-limiting and recovery, which is beneficial to the progression of the infection into stage two and three [1, 2]. Not in vain, lues is often described as a chameleon in clinical dermatology practice [3, 4].

The differential diagnosis of primary syphilis includes other genital ulcerative diseases, such as chancroid, genital herpes, trauma, aphthous ulcers, primary HIV ulcers, lymphogranuloma venereum and granuloma inguinale, neoplasm, autoimmune diseases such as Behçet syndrome, Crohn’s disease, Reiter syndrome, and fixed drug eruptions [3,4].

Although rare, we should bear in mind that the occurrence of a second ulcus durum could be a symptom of a superinfection, only within the incubation period [5]. In contrast, if a second ulcus appeared with different location after the incubation period, following the sexual contact with positive serological test 2-3 weeks after the manifestation, (as in the presented case), that should be considered as a re-infection [5]. The possibility for unusual clinical manifestation, presenting with multiple ulcerations, as well as the possible wide spectrum of differential diagnosis, regarding ulcers in the genital area, should always make the clinician to think in the direction – syphilis [6].
  1. Ma DL, Vano-Galvan S. Images in clinical medicine. Syphilitic chancres of the lips. N Engl J Med. 2013;368(7):e8. doi: 10.1056/ NEJMicm1202329.
  2. Staines K, Sloan P. Images in clinical medicine. Syphilitic chancre of the tongue. N Engl J Med. 2011;365(5):e11. doi: 10.1056/ NEJMicm1011576.
  3. Schon MP, Bertsch HP. Images in clinical medicine. Primary and Secondary Syphilis. N Engl J Med. 2016;374(4):372. doi: 10.1056/ NEJMicm1502476.
  4. Militz H, Hungerer C. Images in clinical medicine. Treponema pallidum--The Great Imitator. N Engl J Med. 2015;373(21):2069. doi: 10.1056/NEJMicm1501265.
  5. GARZON R Jr, FERRARIS A. Luetic superinfection: a documented case on primary syphilis. Rev Fac Cienc Med Cordoba. 1959;17:309-314.
  6. Wasserman S, Vallie Y, Bryer A. The great pretender. Lancet. 2011;377(9781):1976. doi:10.1016/S0140-6736(11)60365-60366.
Listing : ICMJE   

Creative Commons License Open Access by Symbiosis is licensed under a Creative Commons Attribution 4.0 Unported License