Painless penile papule

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Painless penile papule

J Fam Pract. 2015 March;64(3):185-186,188

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References

1. Goldsmith, Lowell, Fischer B. Syphilis. Rochester, NY: VisualDx. Available at: http://www.visualdx.com/. Updated January 19, 2015. Accessed February 13, 2015.

2. Allen C, Woo SB. Aphthous Stomatitis. Rochester, NY: VisualDx. Available at: http://www.visualdx.com/. Updated August 21, 2013. Accessed February 13, 2015.

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7. James WD, Berger T, Elston D. Andrew’s Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Saunders; 2011.

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Diagnosis: Syphilis

The asymptomatic nature and clinical presentation of the patient’s lesion prompted us to suspect syphilis. Skin biopsy of the lesion revealed features that were consistent with syphilis and a rapid plasma reagin (RPR) was positive with a titer of 1:32, confirming our suspicions. (His RPR was checked 3 years earlier and it was nonreactive.) Despite the diagnosis, the patient continued to deny having had any recent sexual encounters.

The “great mimicker”

Syphilis infection occurs after inoculation of Treponema pallidum through microscopic breaks in the mucosal surfaces followed by attachment and invasion of spirochete into host cells. Treponemes then multiply and circulate to the regional lymph nodes and internal organs, leading to a variety of clinical manifestations based on the stage of the infection (primary, secondary, and latent/late), the time that has elapsed since inoculation, and the host’s immune response.

Syphilis is often referred to as the “great mimicker” based on its propensity to present as one of a variety of phenotypes. Syphilitic chancres often mimic other genital ulcers, including those caused by different sexually transmitted diseases such as chancroid (as a result of infection with Haemophilus ducreyi) or granuloma inguinale (Klebsiella granulomatis). Syphilitic chancres may also appear clinically similar to genital aphthous ulcers or cutaneous manifestations of herpes simplex virus.

Chancroid. While the tender ulcer of chancroid has a ragged and undermined border with a dirty gray base, the classic, nontender, syphilitic chancre has a clean base with an indurated border reminiscent of the firm quality of cartilage.¹

Granuloma inguinale presents as one or multiple nontender, friable, soft, red granulating papules that lack the firm border or clean base of the syphilitic chancre.¹

Aphthous ulcers are often soft, shallow, and tender, appearing punched-out with surrounding rims of erythema and clean, white, even bases.²

Genital herpes simplex virus is characterized by tender eroded coalescing vesicles with scalloped, soft borders, contrasted by the indurated smooth rounded border of the syphilitic chancre.¹