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Diagnosis at first sight
Paint ulcers?
¿Úlceras por pintura?
Elisa Hernández de la Torre-Ruiz
Corresponding author
asile93@msn.com

Corresponding author.
, Paloma García-Piqueras, Clara Lacasta-Plasín, Inmaculada Balaguer-Franch
Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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lesion multiplex PCR &#40;<span class="elsevierStyleItalic">Haemophilus ducreyi</span>&#44; <span class="elsevierStyleItalic">Mycoplasma genitalium</span>&#44; <span class="elsevierStyleItalic">Herpes simplex 1</span>&#44; <span class="elsevierStyleItalic">Herpes simplex 2</span>&#44; <span class="elsevierStyleItalic">Treponema pallidum</span>&#44; <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span>&#44; <span class="elsevierStyleItalic">Chlamydia trachomatis</span> ser&#46; A-K&#44; <span class="elsevierStyleItalic">Chlamydia trachomatis</span> ser&#46; L1-L3&#41; and urine PCR for <span class="elsevierStyleItalic">Neisseria gonorrhoeae</span> and <span class="elsevierStyleItalic">Chlamydia trachomatis</span>&#46; We had no prior similar studies for the patient&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Progress</span><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was positive in treponemal &#40;chemiluminescence immunoassay&#59; CLIA&#41; and non-treponemal &#40;rapid plasma reagin&#59; RPR&#41; tests&#44; with RPR titre of 1&#47;1&#46; In addition&#44; the PCR of the sample obtained from the lesion was positive for <span class="elsevierStyleItalic">Treponema pallidum</span>&#46; The rest of the serology and microbiological studies carried out were negative&#46; The patient was diagnosed with primary syphilis with multiple chancres&#46; In view of his history of allergy to penicillin&#44; he was prescribed doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h for 14 days&#46; The skin lesions resolved after about seven days&#46; RPR had become negative in the repeat serology testing at three months&#44; while the rest of the negative serology remained negative&#46; The patient denied any new sexual relations with sporadic partners during the follow-up period&#59; his usual partner was not screened for STI despite our recommendation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Closing remarks</span><p id="par0025" class="elsevierStylePara elsevierViewall">Syphilis is an STI caused by <span class="elsevierStyleItalic">T&#46; pallidum</span> subsp&#46; <span class="elsevierStyleItalic">pallidum</span>&#46; After an incubation period of between 10 and 90 days &#40;mean&#58; 21 days&#41;&#44; a chancre appears at the <span class="elsevierStyleItalic">T&#46; pallidum</span> inoculation site&#44; usually the genital and anal region&#46; The chancre usually consists of a single&#44; painless ulcer with a firm base and hard borders&#46; It is usually accompanied by locoregional lymphadenopathy&#46; This classic clinical presentation of primary syphilis can have less common variations&#44; such as the presence of multiple chancres&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> There is variability in terms of the frequency with which multiple chancres occur in the different series&#44; with some reports as high as 47&#37;&#44; as well as some debate as to whether or not this is more common in HIV-positive patients&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Serology is the main investigation for confirming the diagnosis of syphilis&#46; One of its drawbacks is that it can be negative in the initial stages of the infection&#46; After the appearance of the chancre&#44; the treponemal tests take 5&#8211;15 days to become positive and the non-treponemal tests take 10&#8211;15 days&#46; In these cases&#44; we can opt to repeat the test after the window period or perform direct identification techniques for <span class="elsevierStyleItalic">T&#46; pallidum</span> in the syphilitic chancre&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Classically&#44; the technique used for this purpose was dark-field microscopy&#46; Today there are few health centres where this is still performed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In the 1990s&#44; development began on PCR techniques for the detection of <span class="elsevierStyleItalic">T&#46; pallidum</span>&#44; which now have a sensitivity of 84&#46;6&#8211;89&#46;1&#37; and a specificity of 93&#46;1&#8211;100&#37;&#46; Drawbacks include a higher cost and the lack of immediacy&#44; although the result usually only takes a few days&#46; The multiplex techniques have the added advantage of providing the aetiological diagnosis of the main agents responsible for genital ulcers in one test&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">It is important to maintain a degree of suspicion when diagnosing genital ulcers suggestive of STI&#44; even if they do not coincide with the medical history&#46; The hardness of the lesions should alert us to syphilitic chancre&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they received no funding to conduct this study&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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