Congenital syphilis In utero infection by the spirochete Treponema pallidum can occur after the 16th week of gestation. Intrauterine disease, especially during early pregnancy, may result in spontaneous abortion or in a severely affected infant. Severe disease that is present at birth presents with hepatosplenomegaly, ascites, meningoencephalitis, and severe anemia. Osteochondritis is the most characteristic bone change. The cutaneous findings in severe congenital syphilis include bullae, pustules, macules, and papules.

Fissuring and peeling of the skin are also characteristic. The palms, soles, and periorificial skin are sites of predilection. Syphilitic rhinitis, with a copious and bloody nasal discharge, is an associated finding. If infection occurs late in pregnancy, signs and symptoms may be delayed for several weeks. In these cases, diagnosis is usually made on the basis of a positive syphilis serology in mother and infant. If the disease is allowed to progress, rhinitis, cutaneous macules, and mucous patches may be the presenting signs.

Acquired syphilis Unlike congenital syphilis, acquired syphilis in infants, children, and adolescents follows the classic course of syphilis in adults. Such an infection in a child should be assumed to be the result of sexual abuse. The first event in the development of syphilis is a dark-field positive chancre at the portal of entry of the treponeme. Shortly thereafter, serologic tests for syphilis become positive.

Secondary syphilis usually develops 6 to 8 weeks after the appearance of the chancre. Malaise, low-grade fever, myalgias, and lymphadenopathy are accompanied by a wide variety of cutaneous manifestations. The lesions shown in Fig. 4-3 are condylomata lata around the rectum. Note the moist papules and plaques. Figure 4-4 shows the most common presentation: copper-colored papulosquamous lesions, most commonly on the palms and soles.

Acquired syphilis Sometimes the eruption resembles pityriasis rosea, as seen in Fig. 4-5. Other cutaneous manifestations of secondary syphilis include papular lesions, pustules, nodules, and plaques.

Mucous patches are a common manifestation of acquired syphilis, and appear as white slightly raised plaques on an erythematous base with a serpentine, well-defined border.

Yaws This is a nonvenereal treponematosis that is caused by T pertenue. It is endemic in areas of Central and South America, Africa, and Southeast Asia. The disease is acquired by physical contact, and the majority of cases occur during childhood. An ulceration occurs at the site of the primary inoculation. Secondary lesions are cutaneous nodules or moist or hyperkeratotic plaques; they appear within several weeks and resolve spontaneously. Recurrence of latent disease, with gummata of the skin and bones, may occur many years later.

Erythema migrans (Lyme disease) Lyme disease is caused by the spirochete Borrelia burgdorferi and is transmitted by the pinhead-sized Ixodes ticks. The illness is endemic in large areas of the continental United States. The early cutaneous manifestation, termed erythema migrans, is shown in Figs. 4-8 and 4-9. It consists of an expanding annular lesion around the original tick bite.

Satellite areas of involvement may also be present. Multiple lesions of erythema migrans may represent early disseminated Lyme disease as seen in Fig. 4-11.

Erythema migrans (Lyme disease) Pruritus or burning may be present at the site of the lesion, and the rash may be accompanied by fever, malaise, and regional lymphadenopathy. The systemic manifestations of Lyme disease include neurologic dysfunction (eg., Bell’s palsy), cardiac conduction abnormalities, and arthritis.

Early antibiotic therapy for the typical skin lesion will often prevent the development of the more serious and long-lasting systemic illness. Serologic testing is of some value in diagnosis but results may be negative early on, especially in the absence of neurologic or joint symptoms.

Lepromatous leprosy Leprosy, or Hansen disease, is a chronic multisystem disease that is caused by Mycobacterium leprae, an acid-fast bacillus. The highest incidence of the disease is in areas of South America, Africa, and Asia. It is not rare in children. The clinical manifestations of this illness depend on the host response to infection. At one end of the spectrum is lepromatous leprosy (LL), which represents a diminished host response to the leprosy bacillus. Cutaneous lesions in this form of the disease vary. Macular lesions are symmetrically distributed hypopigmented and erythematous patches. When widespread involvement occurs, the lesions may be difficult to differentiate from normal skin. The lesions pictured here are more infiltrative. Nodular lesions of the earlobe, as shown in Fig. 4-12, are particularly common in LL. Annular plaques and papules (Fig. 4-13) may also be present. LL is the form most likely to cause widespread nerve damage and ocular disease.