EMMA COLEMAN, DO Internal Medicine Residency Program, Cleveland Clinic Secondary syphilis A 39-year-old man presented to the emergency department reporting sev- eral weeks of generalized weakness, headache, nausea, and migratory arthralgia. The patient had exclusively had sex with men, had partici- pated in condomless anal insertive and recep- tive intercourse, and had been in a monoga- mous relationship during the past 6 months. See related editorial, page 514 Physical examination revealed a painful ulcerated plaque on the upper lip (Figure 1), a macular rash with 3 crater-like scarred pain- less lesions (considered to be healing chan- cres) on the glans (Figure 2), a nonpruritic hyperkeratotic maculopapular palmar rash, and bilateral submandibular lymphadenopa- thy. No alopecia, gummas, neurologic def- cits, or ocular or cardiovascular abnormalities were noted. Results of laboratory testing included a positive reactive syphilis immunoglobulin G (IgG) enzyme immunoassay and a positive rapid plasma reagin (RPR) test (titer 1:256). Human immunodefciency virus (HIV) test- ing was negative, and serologic testing demon- strated prior immunization to hepatitis B virus. Given the clinical presentation and laboratory fndings, secondary syphilis was considered the most probable diagnosis. The patient was treated with benzathine penicillin G 2.4 million units intramuscularly. ■ SYPHILIS: A REEMERGING CONDITION Epidemiology The rate of reported primary and secondary syphilis cases in the United States has risen since 2001. 1 Most cases occur in men who have sex with men. 1 Additional risk factors include condomless intercourse and drug use. 2 Signs and symptoms of the 3 stages Primary syphilis begins 2 to 3 weeks after in- oculation of a mucosal surface. 3 This stage is marked by one or more painless chancres and, in some cases, local nontender lymphadenopa- THE CLINICAL PICTURE doi:10.3949/ccjm.84a.16089 ANDRE FIAHLO, MD GI/Hepatology Fellowship, University of Florida, Jacksonville ANDREI BRATEANU, MD, FACP Department of Internal Medicine, Cleveland Clinic FIGURE 1. Ulcerated plaque on the upper lip. FIGURE 2. Macular rash with painless scarred lesions. Untreated primary and secondary syphilis may progress to latent or asymptomatic disease 510 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 84 • NUMBER 7 JULY 2017