[Question #5917] Further questions about syphilis/new case?

20 months ago

Hello doctors, this is a follow-up of sorts to my previous question about doxycycline treatment for syphilis. I believe that my previous course of treatment was successful. It cured (or at least coincided with the end of my) inguinal pain. Last week (Aug 16) I again noticed a small scab (maybe 1/3rd of an inch oval shaped) on the foreskin of my uncircumcised penis.)  This was 9 days after I received brief unprotected oral sex from a female who I did not know well. The scab healed and was entirely gone by the 21st (5 days later). Given the counsel I received here from Dr. Hook that my previous issue was likely not syphilis, I was ready to move forward and dismiss this scab. That was until I started feeling the same tingling and pain in my inguinal area and also under my arms (both of which I also experienced last time). It seems highly coincidental to me to feel these sensations for the second time immediately following the appearance of a genital lesion. I've never experienced these types of sensations in either area except for these two incidences. 

I'd appreciate your thoughts on whether this sounds like syphilis; I'm skeptical for the reasons Dr.Hook suggested in his last post, but the combination of sore+pain in areas where there are lymph nodes has me wondering.

Specific questions:

- Is 9 days too soon from exposure for a chancre to appear?

- Could a chancre resolve completely in five days?

- What about in the case of a second episode of syphilis when presumably you already have the necessary antibodies to effectively fight the bacteria, would that lead to a chancre resolving more quickly & potentially in less than a week?

- Would underarm lymph nodes swell during primary syphilis (i.e. during/immediately after chancre)?

- At three weeks from exposure but with a completely resolved "chancre", am I too soon to test? I'd rather not test at all and just move on, but if I do test I only want to do so once. When would be optimal?

Thank you in advance!

Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
Welcome back to the Forum.   In preparing to answer your question I not only ready our earlier interaction but also read your interaction with Terri.  I'll answer your specific questions first, then have a few additional thoughts.  Before I go there however, can you tell me if the sore you have noticed on this occasion was in about the same part of the penis as your prior lesion?

On to your questions:
1.  The average time for appearance of a syphilis chancre is 21 days but lesions can certainly appear as early as 9 days.
2.  Untreated chancres typically take several weeks to resolve
3.  Having a 2nd episode of syphilis would not necessarily follow a very different course.  If you had syphilis once, or even twice, your blood test for syphilis should be positive.  The blood test for syphilis is always positive it a chancre resolves without therapy.  have you had a syphilis blood test.  if not, a blood test for syphilis would either prove or disprove the diagnosis of syphilis.
4.  No, lymph nodes under the arm would not enlarge with primary syphilis.  FYI, when you look hard enough, most people have palpable lymph nodes under the arms.
5.  Testing.  Please see my comment about testing.  If this was syphilis your test would be positive.

Now for my comment.  Could this be something other than syphilis, herpes for instance.  it was not clear for me that you had a HSV blood test either when we last spoke nor after your discussion with Terri.  HSV blood tests have plenty of problems but what I am hearing is that you have a recurring genital ulcer.  This could be HSV and many herpes tests do not follow the classical pattern/description of HSV.  I don't suggest this often but a HSV IgG blood test might be helpful.  (An IgM test is absolutely useless, please do not get an IgM HSV blood test)

Hope this helps and provides a way forward. EWH
20 months ago
Thanks for your reply, Dr. Hook. Yes, the lesion I noticed this time was in roughly the same area as the previous one. Maybe a 1/2 inch different at most, but basically in the same place. I would not say that there are visibly-enlarged lymph nodes under my arms or in my groin, but I was just getting the same odd feelings in those locations as last time (i.e. sporadic slight pain, occasional "pinched" feeling, sometimes like a stretched muscle). Other than coincidentally with these two instances of penile lesions, I've never experienced these sensations before so it's hard for me to conclude that they are unrelated. To answer your other question, I have not had an HSV blood test. The symptoms I described to Terri actually cleared up shortly after that exchange and have not recurred. Given her analysis that it sounded nothing like herpes, I just moved on. I can certainly get one if you still think it would be prudent!

To update you on my current situation. I saw my doctor yesterday and he prescribed me another course of doxy, which I started last night. I've taken just two pills so far and the odd sensations in my underarm and groin have all-but subsided, just like last time (!)  I'm awaiting the result of the syphilis blood test (I didn't read your response until after I saw him, otherwise I would have asked for the HSV IgG test as well). I appreciate you considering other angles than syphilis because, to be blunt, I had negative tests last time around after the lesion resolved, so I trust you that it was virtually impossible to be syphilis. On the other hand, the apparent response to doxy treatment both times is the only thing that makes me doubt the negative syphilis tests! Any further insight you could provide would be greatly appreciated.

Couple of specific questions too:
- This time my doc prescribed me 10 days of doxy (100mg 2x per day). He said since I'm less than 3 weeks from exposure that would be sufficient and that he doesn't want to over-medicate. Do you think that's correct or would I need more? I know the CDC rec is 14 days 100mg twice per day.
- Is it correct that if my syphilis blood test from yesterday is not positive, then it won't turn positive in the future now that I've started doxy? Of course I suppose if this was syphilis it would have to be positive already since the lesion had resolved?
- Probability-wise, it seems extraordinarily unlikely to acquire syphilis twice in 6 months in the context of heterosexual unprotected oral sex. Do the numbers that you and Dr. Handsfield cite regarding syphilis epidemiology still stand? Or are there parts of the country where it is becoming more common in heterosexual populations?
- Finally, if you didn't cover it in your general response, any thoughts on what might cause the odd sensations in the area of my inguinal and underarm lymph nodes that could be cured by doxy (because that's what seems to be occurring here!) I know that's a broad question and I certainly understand if it's too broad in scope for this forum.
Edward W. Hook M.D.
Edward W. Hook M.D.
20 months ago
Thanks for the additional information.  Like Terri, I would not have suggested a herpes test after your last episode.  At this time however you have had a similar recurrence, something that is far more characteristic of HSV than syphilis.  Remember, herpes tends to resolve spontaneously with recurrences resolving more quickly than initial episodes.  Thus your improvement may be coincidental  Further, as you point out, syphilis is all the more unlikely given your negative blood tests.  As for your specific questions:
1.  The official CDC recommendation is for 14 days of doxycycline.  I suspect less might be curative but the scientific data are for 14 days. if I were treating you for syphilis (not sure that I would) I would give your 14 days.
2.  If this were syphilis and the lesion had resolved, your blood test would be positive.  if your blood test is negative, this makes in almost certain this is not syphilis
3.  Syphilis rates have begun to increase in heterosexuals but not much.  it would be unusual to get syphilis in six moths and have negative blood tests.
4.  I'm sorry, I do not have a good explanation for the unusual sensations under your arms or in your inguinal region that you have been experiencing.  

Hope this helps.  If you really want to sort this out, I would suggest a HSV IgG.  If you decide to do this, please  hold off further replies until you have a result and I will provide final comments.  EWH