26-year-old woman went camping in Connecticut

secondary syphilis

This patient likely has secondary syphilis manifested by a maculopapular rash affecting the palms and soles; she also has evidence of meningitis. The initial chancre ulcer is usually painless and many patients may overlook it.

Compromise of the central nervous system in syphilis can occur in the setting of secondary or tertiary syphilis. Asymptomatic infiltration of the brain and meninges can also occur. In other cases, a person may develop frank meningitis with or without compromise of the cranial nerves. The CSF shows lymphocytic pleocytosis and elevated protein. Typically, results from the Venereal Disease Research Laboratory test will be positive in the CSF. Patients can also develop a meningovascular form of the disease with frank vasculitis that causes strokes. Uveitis and otosyphilis (characterized by hearing loss with or without tinnitus) are also manifestations of secondary syphilis.

Compromise of the central nervous system in tertiary syphilis is now rarely seen. Manifestations include general paresis (dementia) and tabes dorsalis (a disease affecting the posterior aspect of the spinal cord causing ataxia and severe lower extremity pain).

Borreliosis is transmitted by tick bites and can occasionally cause meningitis. The typical rash involves a bull’s eye lesion as the primary manifestation and may be potentially followed by a disseminated rash. However, compromise of the hands and soles is unusual.

Leptospirosis can also cause aseptic meningitis. The disease is acquired by exposure to water contaminated with animal urine or feces. Patients usually have a biphasic course with a severe febrile illness with bacteremia followed by a more immune-mediated subacute condition with nephritis, hepatitis, and hemorrhage. Conjunctival suffusion is a common manifestation, but a rash is relatively rare.

References:

Golden MR, Marra CM, Holmes KK. Update on syphilis: resurgence of an old problem. JAMA. 2003;290(11):1510-1514.

Shapiro ED. Clinical practice. Lyme disease. N Engl J Med. 2014;370(18):1724-1431.

Sperber SJ, Schleupner CJ. Leptospirosis: a forgotten cause of aseptic meningitis and multisystem febrile illness. South Med J. 1989;82(10):1285-1288.

“Secondary Stage Syphilis Sores (Lesions) on the Palms of the Hands. Referred to as ‘Palmar Lesions.".”Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 2 Aug. 2012