Pediatric emergency medicine trisk 1835 1835

One needs a high level of suspicion when viewing rashes in sexually active (or
potentially abused) children to make the diagnosis of secondary syphilis, caused
by the spirochete Treponema pallidum. Manifestations of secondary syphilis
usually occur 6 to 8 weeks after the appearance of the primary lesion, which may
have gone unnoticed. The exanthem extends rapidly and is usually pronounced.
The rash of secondary syphilis is characterized by a generalized cutaneous
eruption, usually composed of brownish, dull-red macules or papules that range
in size from a few millimeters to 1 cm in diameter ( Fig. 88.20 ). They are
generally discrete and symmetrically distributed, particularly over the trunk,
where they follow the lines of cleavage in a pattern similar to pityriasis rosea.
Papular lesions on the palms and soles, as well as the presence of systemic
symptoms, such as general malaise, fever, headaches, sore throat, rhinorrhea,
lacrimation, and generalized lymphadenopathy, help differentiate secondary
syphilis.
Acquired syphilis is sexually contracted from direct contact with ulcerative
lesions of the skin or mucous membranes of an infected individual. Diagnosis
may be presumed after a positive nontreponemal test, such as the VDRL slide
test, rapid plasma reagin (RPR) test, or the automated reagin test. Diagnosis
should be confirmed by a treponemal test, such as the fluorescent treponemal
antibody absorption test, the microhemagglutination test for T. pallidum , or the T.
pallidum immobilization test. Definitive diagnosis may also be made by
identifying spirochetes by microscopic dark-field examination or direct
fluorescent antibody tests of lesion exudate or tissue. Penicillin is the treatment of
choice unless contraindicated, in which case tetracycline, doxycycline,
ceftriaxone, or erythromycin may be substituted. Length of therapy should be
based on duration and stage of infection. Concomitant sexually transmitted
diseases should be sought and treated empirically. HIV testing is recommended
for patients with secondary syphilis.