Thank you again for your interest and questions. You may be retired, but clearly your critical thinking skills remain astute. Your memory of the minutiae is also highly impressive. Your medical training served you well. I hope the following information responds to your inquiries.
Regarding epitrochlear nodes, this is indeed a recognized symptom of secondary syphilis, albeit one that has minimal evidence supporting its presence, frequency, or duration. A recent review in "Lung India", which is the official journal of the Indian Chest Society, identified a paucity of literature about this specific sign. (This article can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846265/.) Nevertheless, as part of good physical examination, clinicians should assess for such nodes, bearing in mind that it is neither sensitive nor specific for syphilis. Other superficial infections peripheral to these nodes and systemic illness (lymphoma for example) may also have this sign; HIV infection is another important differential diagnosis in this situation, as is sarcoidosis. In our article, we included this symptom under the heading of "generalized painless adenopathy", which presents during secondary syphilis and can include cervical, axillary, epitrochlear, and inguinal nodes. The UK, European, CDC, and Canadian guidelines are written similarly.
Regarding inflammation of the parotid gland and its opening, you are again correct that this is possible, although it is likely a very rare manifestation for syphilis. A small number of case reports exist over the last 30 years on this topic; only two could be located via a Medline search, and one of these case reports was from 1984 and may have been mistakenly associated with syphilis instead of HIV (as testing for HIV was not available at this point). It is important to remember, however, that obscure and unique presentations are common for syphilis. It is known as the 'great imitator' for a reason. During its secondary phase, syphilis disseminates and can affect virtually any organ system, creating an almost endless myriad of unique case presentations. A full list of these is well beyond the scope of a clinical practice update. While flu-like symptoms with a rash are considered the classical presentation, many mucocutaneous manifestations are possible, which could involve the parotid gland, as well as many other sites. Renal and hepatic involvement, and arthraligias and myalgias are also possible. In my practice, I have received patients for treatment after they have been worked up for many diseases and illness only to have the final etiology be syphilis. When it comes to mucocutaneous lesions in patients who are sexually active, syphilis should always be a differential diagnosis.
Rapid Response:
Re: Syphilis
Dear Dr. Anand:
Thank you again for your interest and questions. You may be retired, but clearly your critical thinking skills remain astute. Your memory of the minutiae is also highly impressive. Your medical training served you well. I hope the following information responds to your inquiries.
Regarding epitrochlear nodes, this is indeed a recognized symptom of secondary syphilis, albeit one that has minimal evidence supporting its presence, frequency, or duration. A recent review in "Lung India", which is the official journal of the Indian Chest Society, identified a paucity of literature about this specific sign. (This article can be found at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846265/.) Nevertheless, as part of good physical examination, clinicians should assess for such nodes, bearing in mind that it is neither sensitive nor specific for syphilis. Other superficial infections peripheral to these nodes and systemic illness (lymphoma for example) may also have this sign; HIV infection is another important differential diagnosis in this situation, as is sarcoidosis. In our article, we included this symptom under the heading of "generalized painless adenopathy", which presents during secondary syphilis and can include cervical, axillary, epitrochlear, and inguinal nodes. The UK, European, CDC, and Canadian guidelines are written similarly.
Regarding inflammation of the parotid gland and its opening, you are again correct that this is possible, although it is likely a very rare manifestation for syphilis. A small number of case reports exist over the last 30 years on this topic; only two could be located via a Medline search, and one of these case reports was from 1984 and may have been mistakenly associated with syphilis instead of HIV (as testing for HIV was not available at this point). It is important to remember, however, that obscure and unique presentations are common for syphilis. It is known as the 'great imitator' for a reason. During its secondary phase, syphilis disseminates and can affect virtually any organ system, creating an almost endless myriad of unique case presentations. A full list of these is well beyond the scope of a clinical practice update. While flu-like symptoms with a rash are considered the classical presentation, many mucocutaneous manifestations are possible, which could involve the parotid gland, as well as many other sites. Renal and hepatic involvement, and arthraligias and myalgias are also possible. In my practice, I have received patients for treatment after they have been worked up for many diseases and illness only to have the final etiology be syphilis. When it comes to mucocutaneous lesions in patients who are sexually active, syphilis should always be a differential diagnosis.
Warm Regards,
Patrick O'Byrne RN-EC PhD
Competing interests: No competing interests