Similar to primary disease, the acute manifestations of secondary syphilis typically resolve spontaneously, even in the absence of therapy, except in the case of severe cutaneous ulcerations called lues maligna. Occasionally, untreated patients experience additional episodes of relapsing secondary syphilis, which can occur for up to 5 years after their initial episode (Hicks & Clement, 2022). Parenterally delivered penicillin G is the treatment of choice for all stages of syphilis. Treatment recommendations are based upon the pharmacokinetics of the available drugs, the microbe’s slow growth rate (penicillin is active against dividing organisms and requires prolonged antimicrobial exposure for effective killing), the in vitro activity of antimicrobial agents against T. pallidum, and more than 50 years of clinical experience (Hicks & Clement, 2023). Late Syphilis Tertiary syphilis occurs in patients with late syphilis who have symptomatic manifestations involving the cardiovascular system, gummatous disease (granulomatous disease of the skin and subcutaneous tissues, bones, or viscera), and central nervous involvement (particularly general paresis and tabes dorsalis). The clinical events may appear 1 to 30 years after primary infection (Hicks & Clement, 2022). The rash associated with mpox progresses through several stages. ● The rash typically begins as 2- to 5-mm diameter macules. ● The lesions subsequently evolve into papules, vesicles, and then pseudo-pustules (papules that simulate pustules but are predominantly filled with cell debris and do not contain fluid or pus). Lesions are well-circumscribed, deep-seated, and often develop umbilication (a central depression on the top of the lesion). ● The lesions eventually crust over, and these crusts dry up and then fall off. This typically occurs 7 to 14 days after the rash begins. ● The lesions typically begin to develop simultaneously and evolve together on any given part of the body. However, during the global outbreak of mpox beginning in May 2022, not all lesions were in the same stage of development. ● The rash associated with mpox is often described as painful, but it can become itchy over the course of the healing phase (crusts). The number of lesions varies from a few to one hundred. Most commonly, there are 1 to 20 lesions on the skin. Cases with more than 100 lesions have been extremely rare during the 2022 outbreak. In one report, eight cases with more than 100 lesions were identified in an investigation of 197 patients in central London, United Kingdom (Isaacs & Mitja, 2022). All individuals with confirmed exposures to mpox should monitor for symptoms for 21 days. Contacts who remain asymptomatic can continue routine daily activities. If symptoms develop, they should immediately self-isolate and contact the local health department or other designated point of contact (e.g., occupational health for healthcare providers [HCP]) for further guidance. For selected persons at high risk for mpox virus infection due to behavioral or occupational risk factors, preexposure prophylaxis with the MVA vaccine is suggested. Although postexposure vaccination reduces the risk of developing mpox, in some cases, the exposure may not be recognized, or the vaccine may be administered too long after the exposure to prevent disease (Isaacs et al., 2023).
Figure 17. Secondary Syphilis
From Centers for Disease Control and Prevention. (1971). 17043. https://commons.wikimedia.org/wiki/File:Secondary_syphilis-palmar_ rash.PNG. In public domain (CDC, 1971)
MPox Mpox (previously referred to as monkeypox) is a viral zoonotic infection caused by the monkeypox virus and results in a rash similar to that of smallpox. However, historically, person- to-person spread outside the household and mortality from mpox have been significantly less than for smallpox. The rash of mpox can also be similar in appearance to more common infectious rashes, such as those observed in secondary syphilis, herpes simplex infection, and varicella-zoster virus infection (Isaacs & Mitja, 2022). Animal-to-human and human-to- human transmission can occur. The monkeypox virus infection incubation period is usually 5 to 13 days but can range from 4 to 21 days. Mpox has traditionally caused a systemic illness that includes fevers, chills, and myalgias, with a characteristic rash that is important to differentiate from other vesicular eruptions (e.g., varicella, smallpox). However, during the 2022 mpox outbreak, some patients presented with genital, anal, and/or oral lesions without systemic illness. The skin eruption usually occurs between 1 to 2 days before and 3 to 4 days after the onset of the systemic symptoms and continues for 2 to 3 weeks, although rashes without systemic illness have been reported (Isaacs & Mitja, 2022). Figure 18. Mpox
From Mahy, B. W. (1997). 12779. https://phil.cdc.gov/Details. aspx?pid=12779. In public domain
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