Multiple primary penile chancre: A re-emphasize.

Sir,

The incidence of primary syphilis is on a decline because of excellent responses to penicillin and increase in awareness of sexually transmitted diseases (STD) among youths and sexual workers. Syphilis is a STD caused by the spirochete Treponema pallidum. Primary syphilis most often manifests as a solitary, painless chancre that develops at the site of infection within an average of 3 weeks after exposure to T. pallidum.[1] Primary syphilis is most often associated with a single, painless chancre, although it can manifest in other ways (i.e., multiple chancres, painful papules or ulcers, or no lesions). Solitary lesions are often thought to be typical, but multiple lesions frequently occur.[2]

A 20-year-old promiscuous male presented with asymptomatic lesions over the penis since 3 days. There was no history of pain, dysuria or discharge per urethra. On examination, there were four small discrete ulcers; one ulcer situated over distal shaft was discrete, indurated and non-tender. Other three ulcers developed after 3 days of the initial lesion and were superficially situated with regular border and with mild tenderness [Figure 1]. Inguinal examination revealed bilateral inguinal lymphadenopathy with firm discrete shotty lymph nodes with mild tenderness of the right inguinal nodes. The rest of the physical examination was unremarkable.

Figure 1

Multiple chancre on glans and distal part of penis with central necrotic base and erythematous margin

Gram stain of the tissue scraping from the base of ulcer was negative for Haemophilus ducreii and Neisseria gonorrhea. Dark ground microscopic examination revealed refractile T. pallidum only from newer lesion. Venereal Disease Research Laboratory titer was reactive up to 1:32 dilution. Bacterial culture of the tissue sample was negative. A diagnosis of multiple primary chancres was done and the patient was treated with a single intramuscular injection of benzathine penicillin 2.4 million units. On follow-up visit at day 7, lesions were healing reconfirming the diagnosis [Figure 2].

Figure 2

All chancre in healing phase after 7 days of follow-up

Various studies have shown a rise in the prevalence of syphilis in recent years in India. Most of the studies showing a constant or a rising prevalence of syphilis have shown an actual increase in the secondary stage of presentation.[3] Solitary lesions are often thought to be typical, but multiple lesions frequently occur. Atypical clinical features like multiple non-indurated tender chancres and ulcers with irregular and slightly undermined margins, and unilateral lymphadenitis[4] are also seen. Our patient presented with multiple chancres with atypical morphology, among them one was indurated and others were non-indurated. Furthermore seen was unilateral lymphadenitis.

According to Koranne et al. out of 36 untreated primary chancre case four patients with primary syphilis had multiple chancres; two with two ulcers, one with three ulcers and one had four ulcers, three cases had only unilateral lymphadenitis.[5] Lesions that can be confused with the chancre of primary syphilis include herpes simplex virus infection, chancroid, fixed drug eruption, lymphogranuloma venereum, granuloma inguinale (donovanosis), traumatic ulcer, furuncle (boil), and aphthous ulcer. In conclusion, multiple primary chancre with atypical manifestation as in our case appears to be rare we have to reconsider every case of multiple genital lesion to rule out syphilis.