Simultaneous primary and secondary syphilis

Dear Sir,

A 24-year-old unmarried man came to OPD to get himself screened 10 days after he had an unprotected sexual exposure with a known female contact. He had a history of sexual contact with multiple female partners in the previous 2 months. He revealed that he had developed two ulcers in the glans penis 3 days back. Examination revealed two button-like, indurated, non-tender ulcers in the glans penis [Figure 1]. Examination also revealed hyperpigmented scaly macules on bilateral palms and soles, which were non-pruritic [Figures 2 and 3]. His venereal disease research laboratory (VDRL) test titer was reactive and high (1:64). Serological tests for human immunodeficiency virus and hepatitis B and C viruses were negative. A diagnosis of primary syphilis (chancre) and secondary syphilis (palmoplantar papulosquamous syphilid) was made. The patient was administered a single intramuscular injection of 2.4 million units of Benzathine penicillin. His mucosal and skin lesions cleared in 3 weeks. Despite counseling, he did not come back for repeat VDRL and HIV testing.

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Figure 1:

Indurated ulcers on glans penis.

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Figure 2:

Papulosquamous lesions on the sole.

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Figure 3:

Papulosquamous lesions on the sole.

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Simultaneous occurrence of primary and secondary syphilis is rare and is known to occur in the setting of human immunodeficiency virus infection.^[1] It has been reported that at least one-fourth of HIV-infected persons can present with concomitant lesions of both primary and secondary syphilis at the time of diagnosis.^[2] It has been postulated that this occurs because chancre can persist into the secondary stage in HIV,^[3] or due to rapid progression of the disease.

Our patient tested negative for HIV; it is possible, however, that he was in the window period. Simultaneous occurrence of primary and secondary syphilis has been reported outside the setting of HIV too, albeit rarely.^[4] This could also be the case here or it could be a case of secondary infection as he had multiple unprotected sexual contacts. A more rapid dissemination into the bloodstream has been proposed as a probable cause.^[5] Irrespective of the cause, simultaneous presentation of typical lesions of primary and secondary syphilis in the same patient is very unusual and hence, we report this patient.