Secondary Syphilis

dok_zlo — 06.02.2025

A 29-year-old man with well-controlled human immunodeficiency virus (HIV) infection presented to the HIV specialty clinic with a 1-week history of a painful, whitish discoloration on his tongue. He also reported a 4-week history of painful ulcers on the scrotum. Physical examination showed smooth, pink, guttate macules on the tongue that were within a white coating that did not wipe off. No rash, ulcer, or lymphadenopathy was seen on genital examination; the reported lesions were presumed to have already resolved. Empirical treatment for suspected oral candidiasis was initiated, but the patient’s tongue pain did not abate. Four days later, the results of testing performed on the day of presentation showed a serum rapid plasma reagin titer of 1:32 and a positive Treponema pallidum particle agglutination assay. A diagnosis of plaques en prairie fauchée (“mowed meadow”) tongue lesions in secondary syphilis was made. The oral manifestations of syphilis are diverse and may mimic other conditions, which makes diagnosis challenging. The mowed-meadow pattern of tongue lesions in secondary syphilis refers to the presence of depapillated patches of mucosa within a white layering on the posterior tongue. Treatment with a single dose of penicillin G benzathine was given. Seven days after the injection, the tongue lesions had resolved.
Author: Jonathan P. Angel, M.D.
Published February 5, 2025
N Engl J Med 2025;392: e18
VOL. 392 NO. 6

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