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Diffuse lymphadenopathy and fever without a rash: an atypical presentation of secondary syphilis
  1. Arianna Michaels,
  2. Rachel Hughes,
  3. Alia Capone and
  4. Kelly Lacy Smith
  1. Department of Family Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Arianna Michaels; arianna_michaels{at}


A woman in her 30s presented to the emergency department with 4 days of fever, headache and back pain. The patient was admitted for pain control, inability to tolerate oral intake and intravenous antibiotics for presumed diagnosis of pyelonephritis. Following admission, CT of the abdomen/pelvis showed multiple prominent pelvic and inguinal lymph nodes, and the patient was noted to have anterior and posterior cervical and submandibular lymphadenopathy on examination. The differential diagnosis was broadened to infectious, haematological, malignant and autoimmune aetiologies of diffuse lymphadenopathy. Workup included serum studies, imaging, lumbar puncture and lymph node biopsy. Rapid plasma reagin (RPR) returned positive with titre 1:16 and confirmatory reactive Treponema pallidum particle agglutination. With an otherwise unrevealing workup, the diagnosis of secondary syphilis was confirmed. This case highlights the differential and diagnostic approach for diffuse lymphadenopathy and an unusual presentation of secondary syphilis. Additionally, it indicates that secondary syphilis can be present even with a relatively low RPR titre.

  • Infections
  • Infectious diseases
  • Public health
  • Syphilis
  • Sexual transmitted infections (bacterial)

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  • Contributors AM identified and co-managed the case with RH during the patient’s hospitalisation under KS’s supervision, though all four listed authors were involved with patient’s clinical management during hospitalisation. AM is the guarantor. AC and RH performed literature review and contributed equally to development and editing of background, summary, case presentation and discussion. AM performed the patient interview leading to development of the ‘Patient's Perspective’ section, as well as contributed to review of case presentation/discussion. KS contributed to the development of the case report, including editing for clarity and contributing to treatment, outcome and follow-up sections.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.