5-29
Syphilis: Acute (1-3 days): Painless ulcer with rolled border (chancre) heals without Rx in 3-6 weeks
Chronic (>1 month): Secondary syphilis: (see generalized2-4 weeks after chancre, rash including palms and
soles; can also see flat genital warts, loss of hair, patches on the mucous membranes
Tertiary or late (5-20 years) syphilis: gummas (tumor like masses in skin/bone/viscera) neurologic
abnormalities- “neurosyphilis”: posterior column findings such as slapped foot gait, loss of deep tendon
reflexes, loss of position sense or hot/cold sense); also develop abnormal pupillary reflexes, dementia
Auscultation: Syphilis: In late syphilis may hear aortic regurgitation murmur
Palpation: Most patients with genital ulcers develop tender regional adenopathy
Using Advanced Tools: Lab: Gram’s stain pus from bubo (enlarged fluctuant node): large numbers of small
gram negative coccobacilli (see Color Plates Picture 15) in a “school of fish” pattern (chancroid); Giemsa
stain edge of tissue scraping from edge of ulcer: intracytoplasmic bacilli in the macrophages (Donovan
bodies) (Granuloma Inguinale); Giemsa stain of tissue scraping at base of the ulcer (Tzanck smear): observe
for multinucleated giant cells (herpes); RPR (syphilis): may be negative during early stage, and should be
repeated in 4-6 weeks.
Assessment: Diagnosing the cause of genital ulcer disease is mainly based on the clinical history and
inspection.
Differential Diagnosis - Genital ulcers can have non-infectious etiology: fixed drug eruption (take
medication history), Behcet’s syndrome (recurrent symptoms with oral ulcers, conjunctivitis and uveitis),
traumatic injury, malignancy. Secondary syphilis (rash) can be confused with infectious exanthems, drug
reaction, Erythema multiforme. Helpful clues for syphilis are sexual history, prior healed chancre, rash on
palms and soles, and absence of any skin lesions that look like targets.
Plan:
Treatment: Chancroid
Primary: Antibiotics: Ceftriaxone 250 mg IM single dose, needle aspirate fluctuant nodes to avoid rupture
Alternatives: Azithromycin 1 gm po single dose, erythromycin 500 mg po qid x 7 days or ciprofloxacin
500 mg po bid for 3 d
Prevention: Treat all sexual partners dating from 2 weeks prior to onset of symptoms
Return evaluation: Screen for HIV in 4-6 weeks
Treatment: LGV
Primary: Antibiotics: Azithromycin 500 mg po qd x 7 days or 1 gm po each week for 4 doses; drain fluctuant
buboes by needle aspiration, avoid incision and drainage which can cause sinus tracts.
Alternatives: Doxycycline 100 mg po x 21-30 days, ceftriaxone 1 gm IM qd x 14 days, ciprofloxacin
750mg po qd x 21 days or erythromycin 1000 mg po bid x 21 days.
No Improvement/Deterioration: Drug resistant strains have been seen. Expect to see a treatment response
by seven days but prolonged therapy is needed to avoid relapse.
Patient Education: Limit activity if possible during early week of antibiotics to decrease risk of strictures.
Treatment: Granuloma inguinale
Primary: Azithromycin 500 mg po qd x 7 days or 1 gm po each week for 4 doses
Alternatives: Doxycycline 100 mg po x 21-30 days, ceftriaxone 1 gm IM qd x 14 days, ciprofloxacin 750
mg po qd x 21 days or erythromycin 1 gm po bid x 21 days
No Improvement/Deterioration: Drug resistant strains have been seen. Expect to see a treatment response
by seven days but prolonged therapy is needed to avoid relapse.
Treatment: Herpes simplex
Primary: Acyclovir 400 mg q 8 hours x 10-14 days if initial episode, for 5 days if recurrence
Alternative: Valacyclovir 1000 mg q 12 hours x 10 days (use 500 mg po qd for 5 days for recurrence),
Famciclovir 250 mg po q 8 hours x 5-10 days (use 125 mg bid for 3-5 days for recurrence)