CLINICAL MANIFESTATIONS OF SYPHILITIC INFECTION

Primary syphilis

Primary syphilis: after an incubation period of 3 to 4 weeks (ranging from 1 to 13 weeks), a primary lesion (chancre) develops at the site of infection. The initial red papule quickly forms a chancre, usually a painless ulcer with a firm base; when rubbed, it produces clear fluid containing numerous spirochetes (fig. 3–14). Nearby lymph nodes may be enlarged, firm, and non-tender. At the site of invasion of Treponema pallidum microorganisms, a red spot appears. After 2–3 days a papule develops at the site of the red spot. After several days the papule develops into an erosion of regular, round or oval shape with clearly demarcated edges. The base of the erosion is smooth, shiny, as if it were polished (fig. 15–17).

It is rosy red (meat-like red color or the color of rancid fat). Sometimes it may be grayish yellow. The edges are located at the same level of the skin and go down in a saucer-like way to the base. Primary syphiloma is not accompanied by any subjective complaints.

Usually, hard chancre occurs as a single formation but patients with multiple chancres are not uncommon (fig. 18–22). According to the scientific literature, multiple chancres occur in 40–60% of patients. Several chancres may appear simultaneously when there are several portals of entry for the pathogen. They can appear in succession over several days as a result of several sexual contacts during the above period.

Chancres can occur anywhere but are most common on the following:

• penis, anus, and rectum in men;
• vulva, cervix, rectum, and perineum in women;
• lips or mouth in either sex.

Fig. 3. Ulcerative chancre

Fig. 4. Ulcerative chancre

Fig. 5. Giant ulcerative hard chancre

Fig. 6. Ulcerative chancre

Fig. 7. Ulcerative chancre

Fig. 8. Ulcerative chancre

Fig. 9. Ulcerative chancre

Fig. 10. Ulcerative chancre

Fig. 11. Ulcerative chancre

Fig. 12. Ulcerative chancre

Fig. 13. Ulcerative chancre

Fig. 14. Ulcerative chancre

Fig. 15. Erosive chancre

Fig. 16. Marked infiltrate at the base of erosive chancre

Fig. 17. Erosive chancre

Fig. 18. Multiple erosive hard chancres of ventral sulcus and inner side of the foreskin

Fig. 19. Multiple ulcerative chancres

Fig. 20. Multiple chancres

Fig. 21. Multiple chancres

Fig. 22. Multiple ulcerative chancres

It is necessary to note that ulcerative chancres have recently become more prevalent. They are commonly complicated by secondary infection (fig. 23). Ulceration of primary syphiloma predominantly occurs in patients suffering from alcoholism, tuberculosis, anemia and other problems. Furthermore, ulceration of chancres may result from contamination (poor hygiene), infections, and catheterization.

Fig. 23. Ulcerative chancre, balanoposthitis, phimosis

Scleradenitis is not only pathognomonic; it is also one of early symptoms of primary syphilis. Clinical manifestations appear simultaneously with the appearance of hard chancre, sometimes a bit later and sometimes several days earlier. Lymph nodes are typically enlarged, moveable, and non tender. The skin above the lymphatic nodes is unchanged (fig. 24–26).

Fig. 24. Ulcerative hard chancre. Bilateral inguinal scleradenitis

Fig. 25. Ulcerative hard chancre (the same patient)

Fig. 26. Erosive hard chancre on the inner side of the foreskin and regional scleradenitis

The location of a hard chancre depends on the way in which the patient was infected with syphilis. Jean Alfred Fournier (12 March 1832 — 23 December 1914) wrote that there was no guarantees that primary syphilomas would not appear on any part of the human body. Clinical manifestations of hard chancres depend on their location. Their size may vary to a great extent. Giant chancres are often located between the pubis and the abdomen (fig. 27–33).

Fig. 27. Crust-like chancres in the pubis area

Fig. 28. Erosive chancre “imprint” (labia majora and labia minora)

Fig. 29. Erosive chancre (labia minora)

Fig. 30. Hard chancres in the area of the pubis and sulcus coronaries

Fig. 31. Bipolar ulcerative chancres

Fig. 32. Same patient

Fig. 33. Giant ulcerative chancre on the penis (same patient)

In case of extra-genital location hard chancre may be situated on any part of the skin surface and mucous membranes (fig. 34, 35). The most common localization is the oral cavity: mucosae of the lips and tongue, – less often of the cheeks, tonsils and palate. Hard chancre may be located in the area of the anus (fig. 36, 37).

Fig. 34. Ulcerative chancre (extra-genital location)

Fig. 35. Ulcerative chancre (extra-genital location)

Fig. 36. Perianal hard chancre

Fig. 37. Perianal hard chancre