Clinical Insight: The Palm Rash
A short visual-diagnosis case built to test whether you recognize a classic rash distribution and the next diagnostic step.
A 29-year-old man presents to an urgent care clinic for a diffuse rash, low-grade fever, malaise, and sore throat. The rash began on the trunk and now involves the palms and soles. He also reports painless genital ulceration several weeks ago that resolved without treatment. Physical examination reveals generalized nontender lymphadenopathy and scattered copper-colored macules on the palms and soles.
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Diagnosis: Secondary syphilis
The clinical presentation is most consistent with secondary syphilis. The diagnosis is supported by constitutional symptoms, generalized lymphadenopathy, a copper-colored macular rash involving the palms and soles, and a history of a resolved painless chancre. Secondary syphilis may appear weeks to months after primary infection and can mimic many other conditions.
- Key clue: rash involving the palms and soles is a classic board-style clue for secondary syphilis.
- History clue: a painless genital ulcer that resolved spontaneously suggests a prior chancre.
- Diagnostic step: screen with nontreponemal testing and confirm with treponemal testing according to local algorithms.
- Treatment connection: benzathine penicillin G is standard treatment for early syphilis unless contraindications require specialist-guided alternatives.
References
- 1. Hicks CB, Clement M. Syphilis: Screening and diagnostic testing. In: Marrazzo J, ed. UpToDate. Mitty J, ed. Waltham, MA: UpToDate Inc. https://www.uptodate.com. Accessed June 27, 2025.
- 2. Ramchandani MS, Cannon CA, Marra CM. Syphilis: A Modern Resurgence. Infect Dis Clin North Am. 2023;37(2):195-222. doi:10.1016/j.idc.2023.02.006. Accessed December 15, 2024.
- 3. Jay R, Armstrong PA. Clinical characteristics of Rocky Mountain spotted fever in the United States: A literature review. J Vector Borne Dis. 2020;57(2):114-120. doi:10.4103/0972-9062.310863. Accessed November 30, 2024.
- 4. Wetter DA. Erythema multiforme: Pathogenesis, clinical features, and diagnosis. In: Callen JP, ed. UpToDate. Ofori AO, ed. Waltham, MA: UpToDate Inc. https://www.uptodate.com. Accessed July 21, 2025.
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