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Young Man With Painless Penile Ulcer
For 2 weeks, a 30-year-old homeless man has had an enlarging ulcer on the shaft of his penis.
History. The patient had sexual relations with an unknown partner about 3 weeks earlier. The lesion started as a red papule that quickly eroded to form a painless ulcer with serous discharge; it was associated with asymptomatic swelling in the groin.
The patient denies fever or chills, urethral discharge, and urinary symptoms. He has no history of genital or mouth ulceration. There is no rash or joint swelling and no history of chest pain, dyspnea, palpitations, ankle edema, headache, vision problems, cognitive dysfunction, muscle weakness, paresthesia, syncope, seizures, or ataxia.
The patient smokes 1 pack of cigarettes and drinks 6 beers a day; he uses marijuana regularly. He is a sexually active heterosexual with multiple partners. He takes no medication.
Examination. This fairly well-built and well-nourished man is unkempt but not in undue stress. The heart rate is 74 beats per minute and regular; respiration rate, 20 breaths per minute; blood pressure, 124/72 mm Hg. Hydration status is good. There is no evidence of anemia, clubbing, or cyanosis. Examination of the head and neck is unremarkable. There is no thyroid enlargement.
The patient has a single large, painless, punched-out ulcer on the penile coronal sulcus. The ulcer has wide rolled edges and an indurated base and exudes a clear serous discharge. Mildrubbery, nontender, nonfluctuant inguinal adenopathy is noted on the right side. Other systemic examination results are normal.
Laboratory studies. White blood cell (WBC) count, 7200/µL with a normal differential. Hemoglobin level, 12.9 g/dL; platelet count, 180,000/µL; erythrocyte sedimentation rate, 28 mm/h. Urinalysis results are normal. Gram staining of serous discharge from the ulcer reveals a few WBCs but no organisms. No giant cells are seen on Tzanck testing.
The patient is promptly sent to the public health department for dark-field examination of the serous discharge.
Based on the clinical picture and the initial laboratory findings, what is the most likely diagnosis?
A. Primary syphilis
B. Herpetic penile ulcer
D. Granuloma inguinale
E. Squamous cell carcinoma of the penis
(Answer and discussion begin on the next page.)
The dark-field examination shows typical Treponema palladium spirochetes. This finding in a patient with a history of multiple sex partners and a single painless, clean-cut ulcer with indurated base and rubbery, nontender inguinal adenopathy on the ipsilateral side points to a diagnosis of primary syphilis, A.
Further evaluation revealed positive results on rapid plasma reagin (RPR) and fluorescent treponemal antibody absorption (FTA-ABS) testing. Culture of the discharge was negative for herpesvirus. Results of HIV testing were negative.
Management. The patient was treated with benzathine penicillin G, 2.4 million units IM. When he was examined 10 days later, the chancre had healed completely.
EPIDEMIOLOGY AND CLINICAL MANIFESTATIONS
Since 2000, the incidence of primary and secondary syphilis has increased significantly, from 2 to 6 cases per 100,000 to 4 to 7 cases per 100,000. About 64% of cases are in men, many of whom engage in homosexual activity.
The incubation period of primary syphilis is usually between 3 and 4 weeks. The first clinical manifestation is a chancre at the site of the initial treponemal invasion of the dermis, usually on or near the genitals. Chancres are typically larger than 0.5 cm and solitary, although they can be multiple. Most patients do not have constitutional symptoms.
Genital ulcers are generally categorized as either painful or painless (Table). A painless, discrete solitary ulcer is a hallmark of syphilis.
Painful ulcers may be associated with the following conditions:
The workup begins with a targeted clinical history and physical examination. Laboratory studies include serologic tests and, if appropriate, dark-field microscopic examination of serous fluid from the primary chancre. The dark-field examination, which is ordered when primary syphilis is strongly suspected and quick confirmation is needed, reveals typical bright, corkscrew-shaped spirochetes with narrow coils, deliberate forward and backward movement, and rotation about the longitudinal axis.
Serologic testing is more widely used in the diagnosis of syphilis. Two classes of test are used:
Parenteral penicillin G is the drug of choice to resolve the lesions and prevent sexual transmission and late sequelae. The recommended treatment for adults is a single dose of benzathine penicillin G, 2.4 million units IM.
Patient who are allergic to penicillin may be given a 14-day course of oral doxycycline, 100 mg bid, or oral tetracycline, 500 mg qid.
Ceftriaxone, 1 g IV or IM per day for 8 to 10 days, is effective for early syphilis.
A single 2-g dose of azithromycin has been effective in primary syphilis. However, evidence of widespread resistance to azithromycin in T palladium has recently been reported in San Francisco.
|Table - Differential diagnosis of common genital ulcers|
|Syphilis Uncomplicated granuloma inguinale Staphylococci|
|Sexually transmitted Infection with herpes simplex virus type 2 or type 1 Chancroid Complicated granuloma inguinale Nonsexually transmitted Behçet syndrome Squamous cell carcinoma Traumatic|
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