Photo Quiz

A Persistent Lip Ulcer


Am Fam Physician. 2018 Aug 1;98(3):185-186.

A 57-year-old man presented with an ulcer on his upper lip that had been present for approximately two weeks. It was mildly painful and initially oozed honey-colored fluid. He did not recall any blisters or vesicles, and there was no trauma to the area. His history was significant for chlamydia, genital herpes, and well-controlled human immunodeficiency virus (HIV) infection, with a recent CD4 cell count of 426 mm3 (0.43 × 109 per L) and an HIV-RNA level of less than 20 copies per mL. Five years earlier, he was treated with three weekly injections of intramuscular penicillin G benzathine for late latent syphilis. He reported having one regular male sex partner.

He had no recent fevers, oral pain, rhinorrhea, rashes, genital sores, or swollen glands. Physical examination revealed a crusted ulcer (Figure 1) without surrounding induration or tenderness on palpation. He was afebrile and well appearing. He did not have intraoral ulcers or cervical lymphadenopathy.

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Based on the patient's history and physical examination findings, which one of the following is the most likely diagnosis?

A. Aphthous ulcer.

B. Chancroid.

C. Herpes labialis.

D. Pemphigus vulgaris.

E. Primary syphilis.


The answer is E: primary syphilis. The primary syphilis ulcer (chancre) is caused by the spirochete Treponema pallidum. The chancre is found on the genitals in 77% of primary syphilis cases and is sometimes associated with painless regional lymphadenopathy.1 An atypical presentation with multiple ulcers is more common in those with HIV infection.2,3 Syphilis can be transmitted via oral, genital, or anal sex.13 Primary syphilis can be diagnosed with dark-field microscopy, but this is not available at most clinical sites.

A definitive diagnosis requires a nontreponemal test (e.g., a titer from rapid plasma reagin test, the Venereal Disease Research Laboratory test) and a treponemal test (fluorescent treponemal antibody absorption or the T. pallidum passive particle agglutination test). The nontreponemal test helps guide treatment, and the treponemal test confirms the diagnosis

Address correspondence to Adam C. Lake, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Farhi D, Zizi N, Grange P, et al. The epidemiological and clinical presentation of syphilis in a venereal disease centre in Paris, France. A cohort study of 284 consecutive cases over the period 2000–2007. Eur J Dermatol. 2009;19(5):484–489....

2. Bjekić M, Marković M, Sipetić S. Clinical manifestations of primary syphilis in homosexual men. Braz J Infect Dis. 2012;16(4):387–389.

3. Rompalo AM, Joesoef MR, O'Donnell JA, et al.; Syphilis and HIV Study Group. Clinical manifestations of early syphilis by HIV status and gender: results of the syphilis and HIV study. Sex Transm Dis. 2001;28(3):158–165.

4. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1–137.

5. Ship JA. Recurrent aphthous stomatitis. An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(2):141–147.

6. Kirchner JT. Chancroid. 5 Minute Consult. [login required]. Accessed June 11, 2018.

7. Spruance SL, Overall JC Jr, Kern ER, Krueger GG, Pliam V, Miller W. The natural history of recurrent herpes simplex labialis: implications for antiviral therapy. N Engl J Med. 1977;297(2):69–75.

8. Mustafa MB, Porter SR, Smoller BR, Sitaru C. Oral mucosal manifestations of autoimmune skin diseases. Autoimmun Rev. 2015;14(10):930–951.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

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