This man presents with a rash consistent with secondary syphilis and should be treated with benzathine penicillin. The most common clinical manifestation of secondary syphilis is a generalized rash that is typically nonpruritic and often involves the palms and soles. Lesions may be macular, papular, or pustular. Silvery gray erosions with an erythematous border may be visualized on mucosal surfaces (mucus patches). Patients with secondary syphilis frequently have generalized lymphadenopathy and systemic symptoms. A single dose of 2.4 million units given intramuscularly is the treatment of choice, preferably at the time of presentation if follow-up cannot be guaranteed. Syphilis among men who have sex with men, particularly in urban areas, has increased significantly in the past several years, so recognition of the characteristic clinical presentation is essential. Diagnostic testing with syphilis serologic assessment should still be obtained to confirm the diagnosis and provide a baseline titer that can be followed to assess the adequacy of therapy. In addition, the patient should be screened for other sexually transmitted infections including HIV, Neisseria gonorrhoeae, and Chlamydia trachomatis infections; specimens for N. gonorrhoeae and C. trachomatis should be obtained from all potentially exposed anatomic sites (throat, urethra, and anus) on the basis of the sexual history obtained.
A single 2-g dose of azithromycin is effective for the management of early syphilis; however, resistance associated with treatment failure has been reported recently. Azithromycin should be used only when treatment with penicillin or doxycycline (the recommended alternative in the setting of penicillin allergy) is not possible.
Ceftriaxone may be used to treat neurosyphilis as an alternative in a patient allergic to penicillin whose reaction is not life threatening, but it is not recommended in any other setting.
Although an allergic reaction may be in the differential diagnosis of a rash, involvement of the palms and soles is uncommon. Empiric treatment with methylprednisolone in a person with a high-risk sexual history is inappropriate.
