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Net Letter
87 (
); 321-321

Syphilis on the rise: A series of 12 cases with mucocutaneous features over a short span

Department of Dermato Venereology, Madurai Medical College and Government Rajaji Hospital, Madurai, Tamil Nadu, India
Corresponding author: Dr. Nithya Mohan, 258, Kamarajar Salai, Madurai - 625 009, Tamil Nadu, India.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Rajakumari S, Mohan N, Prathap A. Syphilis on the rise: A series of 12 cases with mucocutaneous features over a short span. Indian J Dermatol Venereol Leprol 2021;87:321-321.


Syphilis, the sexually transmitted bacterial infection, was brought under control with the advent of penicillin. However, in recent times, rise in the incidence of syphilis has been reported by the Center for Disease Control and Prevention.1 Here, we report a series of 12 syphilis cases with varied clinical features, diagnosed over a short span of two months (July to August 2018) [Table 1] in the sexually transmitted diseases outpatient department of Madurai medical college, Tamil Nadu.

Table 1:: Details of patients
Patient number Age in years/ sex Marital status Complaints Exposure history Darkfield microscopy Reactive RPR titer HIV screening
1 30/male Unmarried Painful Genital Heterosexual, RE: 2 weeks Negative NR NR
ulcer—10days back with unknown female and unprotected
2 20/male Married for 6 Painless genital Heterosexual Negative NR NR
months ulcer—1 month RE: 3 days back, marital, unprotected Denies PMC and EMC
3 22/female Married Vaginal discharge-1 Heterosexual Not done 1:128 NR
(wife of case 2) month, Painless RE: 3 days back, marital,
genital ulcer -5 unprotected
months back Denies PMC and EMC
4 31/male Unmarried Skin rash - 1 and Heterosexual Negative 1:32 NR
1/2 months RE: 3 months back with known female and
5 38/female Married for 15 Skin rash, painless Heterosexual Negative 1:128 NR
years genital ulcer -1 week RE: 6 months back, marital, unprotected Denies PMC and EMC
6 45/male Unmarried Skin rash - 15 days Homosexual Negative (from 1:32 NR
RE: 1 month back with serous exudate on
unknown male (anoinsertive) and unprotected removing scales)
7 25/male Unmarried Painless genital Heterosexual Positive(from 1:8 NR
ulcer- 4 days RE: 2 months back serous exudate on
with known female and unprotected removing scales)
8 39/male Married for 10 Skin rash - 4 month Heterosexual Not done 1:32 Reactive on
years RE: 4 months back, marital, (dry lesion) Tenofovir
unprotected 300 mg +
Denies PMC and EMC Lamivudine 300
mg + Efavirenz
600 mg regimen
from February
9 44/female (wife Married Partner screening Heterosexual Negative 1:8 Reactive on
of case 8) RE: 4 months back, marital, Tenofovir
unprotected 300 mg +
Denies PMC and EMC Lamivudine 300
mg + Efavirenz
600 mg regimen
from August
10 28/male Married for 10 Perianal growth - Heterosexual Negative 1:64 NR
years 40days RE: 1 and 1/2 years, marital, unprotected Denies PMC and EMC
11 22/male Unmarried Perianal growth-2 Homosexual Positive 1:4 NR
weeks RE:1 1/2 year back with known male (ano and oro receptive) and unprotected
12 25/male Unmarried Genital ulcer-3 days Homosexual RE: 4 days back with unknown male (anoinsertive) and unprotected Negative 1:64 NR

All the patients denied history of intravenous drug abuse, previous blood transfusion and surgeries. Except for cases 11 and 12 all patients denied a history of previous venereal disease. There was no history of abortion in female cases. NR: nonreactive; RE: recent exposure; PMC: premarital contact; EMC: extramarital contact; RPR: rapid plasma regain test

The first case, syphilitic chancre with genital herpes, presented with multiple discrete superficial ulcers on glans penis with few forming geographic pattern [Figure 1a]. Multinucleated giant cells were demonstrated by the Tzanck smear. A circular non-tender ulcer of size approximately 1×1 cm with a clean floor and an indurated base was noted on coronal sulcus [Figure 1b]. Routine smears from this ulcer were negative. A clinical diagnosis of herpes genitalis with chancre was made and the patient treated with tablet acyclovir. There was complete resolution of sores on the glans penis in a week but the ulcer on the coronal sulcus was persistent. After treating with injection benzathine penicillin the persistent ulcer healed in a week’s time. The second case presented with multiple, discrete, nontender ulcers of size approximately 0.5×0.5 cm on the glans and inner aspect of the prepuce with edematous border and clean floor [Figure 2] and was diagnosed as multiple chancre with non-gonococcal urethritis.

Figure 1a:: Genital herpes
Figure 1b:: Chancre
Figure 2:: Multiple chancres

A total of eight cases had secondary syphilis. The spouse of the multiple-chancre patient had bilateral epitrochlear lymphadenopathy, bacterial vaginosis and trichomoniasis. Another patient had erythematous patches and plaque (few were scaly) on the face, trunk and extremities with paronychia on the great toe. He had an annular erythematous plaque with central pigmentation on the cheek and a mucous patch with erythematous papules on the hard palate [Figures 3a-d]. The fifth case had a palmoplantar rash (psoriasiform plaque on sole) [Figure 4], mucous patches on the hard palate and anterior faucial pillar. The sixth case had an annular scaly plaque on the scrotum and erythematous macules on palms [Figure 5].

Figure 3a:: Papulosquamous rash on trunk and genitalia
Figure 3b:: Biet's collarette
Figure 3c:: Annular plaque on cheek
Figure 3d:: Mucous patch with papules
Figure 4:: Psoriasiform plaques on soles
Figure 5:: Annular plaque on scrotum

The next patient had scaly plaque on glans, inner aspect of prepuce and penis [Figure 6]. The patient living with HIV (CD4 count: 401) had lichenoid plaques on scrotum [Figures 7a and b] and palmoplantar rash. His spouse having HIV infection (CD4 count: 432) presented with scaly patches on palms and a mucosal patch on the hard palate [Figure 8]. The tenth patient had flat-topped grayish papules on genitalia, scaly plaques on palms [Figure 9a] and pigmented macules on soles. The perianal mass was excised in a private hospital suspecting it to be a wart but few grayish papules [Figure 9b] were present.

Figure 6:: Scaly plaques on penis
Figure 7a:: Lichenoid plaques on scrotum
Figure 7b:: Lichenoid plaques
Figure 8:: Mucous patch on hard palate
Figure 9a:: Condyloma lata
Figure 9b:: Perianal papules

The eleventh patient, a case of persistent chancre in secondary syphilis [Figures 10a-c], treated with injection ceftriaxone in February 2017, had a clinical relapse in the form of perianal condyloma lata and he denied reexposure. The reinfection of syphilis in a promiscuous individual presented with genital ulcer and reactive rapid plasma regain test in high titer. He was a treated case of late latent syphilis on irregular follow-up.

Figure 10a:: Condyloma lata
Figure 10b:: Persistent chancre
Figure 10c:: Perianal condyloma lata

The relevant bedside and screening tests for sexually transmitted infections were done and syphilis was confirmed in all by positive treponema pallidum hemagglutination test. None of them had systemic involvement and most had only minimal but varied clinical features that were easy to miss if not suspected. The serological tests played a vital role in their diagnosis. After proper counseling, all were treated as per the Center for Disease Control and Prevention guidelines with injection benzathine penicillin and also the associated sexually transmitted infections. The mucocutaneous features resolved completely over 1–4 weeks and they are all on follow-up (2 years for those without HIV infection and 5 years for people living with HIV/AIDS). Partner screening was done and the epidemiological treatment was given to the traceable contacts [Table 2]. We had difficulty in tracing partners other than spouse even with proper counseling. This may indicate missed cases in the society which can lead to further spread of syphilis.

Table 2:: Partner screening
Case number Marital status Exposure history Number of partners Epidemiological dose Index case and treatment
1 Unmarried 2 weeks back with unknown female and 1 - Not traced
2 Married 3 days back, marital, unprotected 1 - Wife: Treated
3 Married 3 days back, marital, unprotected 1 - Not traced
Wife of case 2
4 Unmarried 3 months back with known female and 1 - Informed by a phone
unprotected call—not traced
5 Married 6 months back, marital, unprotected 1 Given to husband (RPR and Not traced
6 Unmarried 1 month back with unknown male and 4 - Not traced
7 Unmarried 2 months back with known female and 2 - Not traced
unprotected 4 months back with unknown female and
8 Married 4 months back, marital, unprotected 1 - Not traced
9 Married 4 months back, marital, unprotected 1 - Not traced
Wife of case 8
10 Married 1 and 1/2 years, marital, unprotected 1 - Not traced
11 Unmarried 1 year back with known male and unprotected 1 - Not traced
12 Unmarried 4 days back with unknown male and 7 - Not traced

TPHA: treponema pallidum hemagglutination test, RPR: rapid plasma regain test

The reproductive rate (R) of a sexually transmitted infection = average rate of exposure X average likelihood of infection (33% in syphilis) × duration of infectiousness (about 2 years in untreated syphilis).2 The average rate of exposure depends on the rate of partner change and the likelihood of an infected partner.3,4 If R >1, it indicates increasing incidence and R< 1 indicates decreasing incidence. The strategies to decrease the reproductive rate are creating awareness among public, behavior change intervention in infected persons, using barrier methods, early diagnosis and treatment of the sexually transmitted infection and epidemiological treatment.3

The clustering of infectious syphilis cases over a short time and challenges in partner treatment and tracing tends to increase the direct variables of the reproductive rate of syphilis. This will increase the prevalence of syphilis especially latent syphilis in the future. Hence, this may be the sign of an impending epidemic and stringent implementation of sexually transmitted infection control measures are needed at present.


Dr. G. Geetha Rani (Professor and Head), Dr. S. Murugan (Associate Professor), Dr. R. Sudha (Assistant Professor), Dr. S. Durgadevi (Assistant Professor), Dr. S. Sumithra (Assistant Professor), Mrs. Shanmugapriya (Counselor), Department of Dermato Venereology, Madurai Medical College, Madurai, Tamil Nadu for their valuable support in manuscript preparation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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