Image 26. This gentleman, on the Pacific coast of Mexico for one week, swimming in the ocean, on day 5 developed a mildly itchy maculopapular rash, initially trunkal but spreading to the limbs. This picture was taken 19 days after onset. There had been no warning posted concerning the swimming in that part of the coast.. He had no allergies. The diagnosis was

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Image 26  A diagnosis of secondary syphilis was made. His VDRL was positive (1:16), and the rash became more marked and uncomfortable for a day, 2 days after his first dose of intramuscular penicillin. His VDRL rose to 1:64 in the next month and dropped to 1:2 two months later. A biopsy revealed "superficial and mid-dermal perivascular lymphohistiocytic infiltrates with frequent plasma cells and endothelial cell hyperplasia suspicious of secondary Lues" There was no history of a chancre but he had had other STDs in the past. We were not convinced that he had a Jarisch-Herxheimer reaction.

since Sept 29, 2005