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Mauro Romero Leal Passos
Editor-in-Chief
Gutemberg Leão De Almeida Filho
Ivo Castelo Branco Coêlho · Luiz Carlos Moreira
Edilbert Pellegrini Nahn Junior · José Eleutério Junior
Associate Editors
Atlas of Sexually
Transmitted Diseases
Clinical Aspects and

Differential Diagnosis
123
Atlas of Sexually Transmitted Diseases
Editor-in-Chief
Gutemberg Leão De Almeida Filho
Ivo Castelo Branco Coêlho • Luiz Carlos Moreira
Edilbert Pellegrini Nahn Junior • José Eleutério Junior
Associate Editors
Atlas of Sexually Transmitted

Diseases
Clinical Aspects and Differential Diagnosis
Editor-in-Chief
Universidade Federal Fluminense
Niterói, Rio de Janeiro, Brazil
Associate Editors
Gutemberg Leão de Almeida Filho Edilbert Pellegrini Nahn Junior
Department of Obstetrics and Gynecology Clínica Médica - Dermatologia
Institute of Gynecology Faculdade de Medicina de Campos
Federal University of Rio de Janeiro Campos dos Goytacazes, Rio de Janeiro, Brazil
Rio de Janeiro, RJ, Brazil
José Eleutério Junior
Ivo Castelo Branco Coelho Motherhood and Child Departament
Tropical Medicine Nucleus (NMT ) Federal University of Ceará
Federal University of Ceará (UFC) Fortaleza, Ceará, Brazil
Fortaleza, Ceará, Brazil
Luiz Carlos Moreira
Odontoclinic Department
Federal Fluminense University
Niterói, Rio de Janeiro, Brazil
Translation from the Portuguese language edition: “Atlas de DST & Diagnóstico Diferencial” by
Mauro Romero Leal Passos (ed), © Livraria e Editora Revinter LTDA, 2012. Original publication
ISBN: 978-85-372-0406-1.
ISBN 978-3-319-57468-4 ISBN 978-3-319-57470-7 (eBook)

https://doi.org/10.1007/978-3-319-57470-7
Library of Congress Control Number: 2017953048
© Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
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Foreword
In these days of Internet with facial recognition tools spreading from airports to banks and
social media with photo sharing apps, do we still need a bound paper reference book? Yes, we
do! We need a solid academic book, easy to search, with good pictures and sound practical
tips. Professor Mauro Romero Leal Passos and his team of Brazilian leading scientists have
created such a reference book. The differential diagnosis of sexually transmitted diseases is an
art combining questionnaire, risk evaluation, physical examination, laboratory tests selection
as well as counseling. The physical examination is still the most important stepping stone to
proper patient management. With so many diseases with features overlapping we need a solid
reference book. We may be a few years before we can take a picture and wait few seconds for
a diagnosis to come in through Internet but before it becomes a reality I do suggest you acquire
Professor Mauro’s reference book for your practice either in dermatology, venereology, urol-
ogy, family medicine, or gynecology-obstetrics. Your management skills and your teaching
will improve, your students will gain experience faster, and, even more important, the well-
being of your patients will improve more rapidly.
Have a great reading and viewing.
Marc Steben
Québec National Public Health Institute,
Clinique A rue McGill, Montreal,
QC, Canada
v
Preface
What a Professional Involved in STD Should Know
Treating STD/genital infections should consider immediate actions and should not be trivial-
ized, for simpler the case may seem.
In latest epidemiological data published by the international literature, the syndromic
approach on STD is not supported by the medical perspective with scientific evidence and
etiologies’ epidemiology involving the main syndromes. Nevertheless, there may be good
results in specific situations in the short term.
We believe the main purpose of professionals working in any Science field is to treat other
people the way they would like to be treated.
One fact is to treat a patient with a syndromic approach methodology in a specific situation.
Another one is to consider the syndromic approach as the only STD assistance policy for the
whole country, not valuing nor implementing specialized centers of public and/or private med-
ical attention for the research and epidemiological surveillance on STD.
Considering that STD is not decreasing in the world and the naive actions-based approaches
do not reveal solid and lasting progress. On the contrary, the numbers of STD cases advanced.
In 2000, the World Health Organization (WHO) estimated 340 million new cases of four
curable STD per year (Trichomoniasis 172 million, Chlamydia 92 million, gonorrhea 62 mil-
lion, syphilis 12 million).
In 2008, the same WHO showed other estimates: 498.8 million of same curable STD
(Trichomoniasis 276.4 million, Chlamydia 105.7 million, gonorrhea 106.1 million, syphilis
10.6 million).
To make this situation more difficult, gonococcal strains resistant to multiple antibiotics,
including quinolone, are practically a problem all over the world. Furthermore, we all know (or
should know) that combating the antibiotics overuse is one of the main questions in the fight
against antimicrobial resistance.
STD Fact Sheet, February 2013, from CDC—Incidence, Prevalence, and Cost of Sexually
Transmitted Infections in the United States—reveals:
CDC’s estimates of STI (USA, 2008):
–– Annual new infections (incidence), 20 million dollars, USA, 2008.

–– Total infections (prevalence), 110 billion dollars, USA, 2008.
–– Total medical costs: 16 billion dollars, USA, 2010.
Is it possible to imagine what the numbers for South Africa, Brazil, China, India, Russia
would be? Just to name a few countries.
In July 9, 2014, during the “2014 STD Prevention Conference/CDC”, Atlanta, USA, pro-
fessor King K. Holmes, in a brilliant lecture entitled Progress and challengers in the evolution
of sexual health and STI prevention, wrote the first phrase in his last presentation slide: At
First: Just need more and better diagnostic and treatment.
He did not speak only to Americans; he did it to the entire world. Oddly enough, we are
lacking basic actions of medicine in STD area.
vii
viii Preface
Clinical sense, common sense, knowledge of epidemiology in this field (local and global),
and individualized service related to a specific time have to be constant in every medical assis-
tance. This is different from not seeking the better standards of medical care routinely. Guessing
should be for activities such as theatre, cinema, joking among friends.
Therefore, It Should Not Be Postponed
–– Excellent anamnesis.
–– Satisfactory physical examination and complementary examinations.
–– Counseling (on health education, being available to listen).
–– Offering serology for syphilis, HIV, hepatitis markers especially anti-HBS, HBsAg and
anti-HCV.
–– Emphasizing the adherence to the treatment (supervised therapy in the query or make the
medication available at the time of the appointment).
–– Emphasizing the importance of appointment/examination/treatment of sexual partners.
–– Emphasizing the importance of periodical physical examinations (gynecological/prostate).
–– Emphasizing the importance of vaccine schemes available in the country (hepatitis A, hepa-
titis B, HPV).
–– Knowing that medications can be acquired in case they are not available to patients during
the appointment. And that the so-called generic medications do not always cost less.
–– Providing condoms (male/female).
–– Scheduling return to the medical appointment for control/review.
–– Being available or provide appointment to sexual partners.
–– Asking the patient, especially at the end of the anamnesis, the following question: Is there
something I didn’t ask or talked about that you would like to tell me?
–– Notifying the cases to public health organizations for a proper epidemiological
surveillance.
–– Claiming, demanding the best human and technical resources available for a good medical
care, whether public or private. Remember once again that our main objective is to treat
everyone the way we ourselves would like to be treated.
Major Syndromes to Be Observed in STD/Genital Infections
–– Genital ulcers (genital herpes, syphilis).

–– Urethral discharge (gonorrhea, Chlamydia).
–– Vaginal discharge (bacterial vaginosis, candidiasis, Trichomoniasis).
–– Endocervicitis/pelvic pain (gonorrhea, Chlamydia).
–– Testicular pain/swelling (gonorrhea, Chlamydia).
–– Proctitis (gonorrhea, Chlamydia).
–– Ophthalmia (gonorrhea, Chlamydia).
Notes
There may be more than one agent and/or more than one syndrome concomitantly.
Sometimes, a syndrome simulates another. For example, gonococcal ulcerated balanitis or
cervical and/or vaginal wounds causing vaginal discharge.
Preface ix
Many genital changes, even some infectious diseases, do not configure STD.
More than 20% of genital ulcers, even employing good laboratory resources, are undiag-
nosed. Several cases are autoimmune diseases/unknown origin.
In many situations, systemic diseases can cause genital repercussions, with cutaneous and
mucosal rush or genital ulcers.
Caution and good sense should be observed not to exaggerate the use of antibiotics, espe-
cially in associations.
The indiscriminate use of antibiotics is an important factor to be combated in order to
reduce the microbial resistance to drugs.
Important
People with immunodeficiency (AIDS, malignant neoplasm, use of immunosuppressant) can

have atypical and/or exaggerated responses to many infections. For these people, treatment
may require increased dose and time of use, and even a change of the administration path of
anti-infective medicament. Repeating the scheme and/or hospitalization is not unusual.
Women in their teens, in perimenopause, and young gay men are groups in which there has
been a great progress in the incidence of HIV infection in several countries during the last years.
Vaginal discharge (due to inflammatory process or microbiota imbalance) exposes woman
to great vulnerability to HIV (susceptibility increases in case she is seronegative) and transmis-
sion of the virus (transferability increases in case she is positive). Trivializing the medical care
in these cases means trivializing the life quality of a community.
Sensitivity of a Laboratory Test
–– Measures the test ability to detect an infection.

–– Is the maximum concern about the population with a high prevalence of the disease, as it
happens in the STD clinics.
–– The sensitivity appraises the proportion of positive individuals among all infected patients.
Specificity of a Laboratory Test
–– Measures the test’s ability to properly exclude the uninfected individual. It is the maximum
concern with the tests of the population with a low prevalence of the disease, as is the case
of the family planning clinics and private clinics in general.
–– The specificity appraises the proportion of individuals uninfected with negative test.
Reflection
Finally, the items we have been pointing out and divulging for a long time are the following:
When treating (attending) a person suspected STD, perhaps it is easier or more didactic to
recommend what Not to do:
–– A prejudiced attitude towards gender/sexuality, skin color, education, socioeconomic and

cultural status, occupation, religious belief, place of habitation or birth.
x Preface
–– Provide diagnosis and treatments based on assumptions without verifying the epidemio-
logical, laboratory and clinical data, because not all there is in the genitals is sexually trans-
mitted. On the other hand, extragenital signs and symptoms can (co)exist with STD/HIV,
especially syphilis, HPV.
–– Not invite the patient to think about the attitude towards all situations involved nor provide
basic information about the problem.
–– A judge attitude (make a judgment of the patient and/or situations involving the case).
–– Ignore all emotional and existential story involved in the case.
–– Fail to make good use of the meeting with the patient to start/expand the process of health
education/prevention of other damages to the health. For example, trying to get to know the
vaccination status of the patient (hepatitis A, hepatitis B, HPV, flu).
–– Avoid “being ashamed”, postpone asking other colleagues’ opinion about cases of chronic
evolution, recidivism and resistant to treatments already made, especially, but not only, in
situations where the diagnosis is not fully established. The well-being and the full recovery
of the patient is fundamental. Not the “wisdom” of the doctor.
–– Overvalue publications on cost-effectiveness. Generally, these studies are made in very dif-
ferent environments, usually public health units, where most professionals treat
STD. Although the medical practice has a broad and collective vision, it is a custom/per-
sonal assistance. At least for us, to quantify the value (and welfare) of human beings (and
their families) is a task that we are not able to perform. Neither our goal.
–– The absolute majority of the actions that have caused (and still cause) great impact to a huge
number of people start with a decision/personal attitude.
–– We can mention as mere examples: discovery of the tuberculosis Bacillus; the discovery of
penicillin; proposal of a bill requiring the Federal Government of Brazil to ensure antiretro-
viral therapy in the public health system; free vaccination scheme against HPV, since 2007,
for girls and women up to 26 years of age, and for boys, in 2014, by the Government of
Australia.
Niterói, Rio de Janeiro, Brazil Mauro Romero Leal Passos

Contents
1 The Skin and Eruptives Lesions �� 1

2 Syphilis�� 15
3 Genital Herpes�� 105
4 Chancroid �� 135
5 Lymphogranuloma Venereum: LGV �� 151
6 Donovanosis�� 161
7 Gonococcus and Chlamydia Infection �� 173
8 Vulvovaginitis �� 203
9 Infection with Human Papillomavirus (HPV)�� 239
10 Some HIV/AIDS Manifestations�� 321
11 Differential Diagnosis�� 361
xi
Contributors
Editors
Gutemberg Leão de Almeida Filho, M.D., Ph.D. Institute of Gynecology, Federal

University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
Ivo Castelo Branco Coêlho, M.D., Ph.D. Nucleus of Tropical Medicine, Federal University
of Ceará, Fortaleza, CE, Brazil
José Eleutério Jr., M.D., M.Sc., Ph.D., M.I.A.C. Department of Maternal and Child
Health, Federal University of Ceará, Fortaleza, CE, Brazil
Luiz Carlos Moreira, D.D.S., M.Sc. Fluminense Federal University, Niterói, RJ, Brazil
University of Grande Rio, Rio de Janeiro, RJ, Brazil
STD Sector, Fluminense Federal University, Niterói, RJ, Brazil
Edilbert Pellegrini Nahn Jr., M.D., M.Sc. Clínica Médica - Dermatologia, Faculdade de
Medicina de Campos, Campos dos Goytacazes, RJ, Brazil
Mauro Romero Leal Passos, M.D., Ph.D. Sexually Transmitted Diseases Sector,
Department of Microbiology and Parasitology, Fluminense Federal University, Niterói, RJ,
Brazil
Colaboradores
Humberto Abrão Humberto Abrão Laboratory, Belo Horizonte, MG, Brazil

Benjamim Baptista de Almeida, M.D. General Hospital of Bonsucesso, Rio de Janeiro,
RJ, Brazil
Márcia C.A. Araujo Frias, M.D. Obstetrics and Gynecology and STD, STD Sector of
Fluminense Federal University, Niterói, RJ, Brazil
Wilma Nancy Campos Arze, M.D., M.Sc. Ginecologia Obstetrícia da Universidade
Federal de Integração Latino Americana UNILA, Foz de Iguaçu, PR, Brazil
Rubem de Avelar Goulart Filho, R.N., M.Sc. STD Sector, Fluminense Federal University,
Niterói, RJ, Brazil
Nero Araújo Barreto, Ph.D. Department of Microbiology and Parasitology, Fluminense
Federal University, Niterói, RJ, Brazil
Edmund Chada Baracat, M.D., Ph.D. Gynecology, University of São Paulo, São Paulo,
SP, Brazil
xiii
xiv Contributors
Carla Aguiar Bastos, M.D. STD Sector, Universidade Federal Fluminense, Niterói, RJ,
Brazil
Adele Schwartz Benzaken, M.D., Ph.D. Department of Surveillance, Prevention and
Control of STIs, HIV/AIDS and Viral Hepatitis, Secretariat of Health Surveillance—SVS,
Ministry of Health of Brazil, Brasília, DF, Brazil
Hugo Boechat, M.Sc. National Institute of Infectology of the Oswaldo Cruz Foundation,
Ken Borchardt, Ph.D. Center for Biomedical Laboratory Science, San Francisco, CA, USA
Vaulice Sales Café, Ph.D. Microbiology, Federal University of Ceará, CE, Brazil
Altamiro Vianna e Vilhena de Carvalho, M.D., Ph.D. Fluminense Federal University,
Newton Sérgio de Carvalho, M.D., Ph.D. Department of Gynecology and Obstetrics,
Hospital das Clínicas da Federal University of Paraná, Curitiba, PR, Brazil
Dennis de Carvalho Ferreira, D.D.S., R.N., M.Sc., Ph.D. Veiga de Almeida University
and Estacio de Sá University, Rio de Janeiro, Brazil
Eunice de Castro Soares, Ph.D. Fluminense Federal University, Niterói, RJ, Brazil
Sílvia Maria B. Cavalcanti, Ph.D. Virology, Federal Fluminense University, Niterói, RJ,
Brazil
Jussara Barros Cerrutti, M.D. Imperatriz Health Department, Maranhão, MA, Brazil
Maria Clara D’Araujo C.M. Chaves, M.D., M.Cs. Fluminense Federal University,
Cláudio Cesar Cirne-Santos, B.Sc., Ph.D. Laboratory of Molecular Virology , Fluminense
Federal University, Niterói, RJ, Brazil
Cristina Mendonça Costa, M.D., Ph.D. Fluminense Federal University, Niterói, RJ, Brazil
Paulo da Costa Lopes, M.D., Ph.D. Institute of Gynecology, Federal University of Rio de
Janeiro, Rio de Janeiro, RJ, Brazil
André L. L. Curi, M.D., Ph.D. Uveitis/Aids Sector of the Ophthalmology Service,
Luiz Lúcio Daniel, M.D. Department of Health of the Federal District, Brasília, DF, Brazil
Geraldo Duarte, M.D., Ph.D. Tocoginecology, School of Medicine, Ribeirão Preto,
University of São Paulo, São Paulo, SP, Brazil
Silvana Khouri Duarte, M.D. Fluminense Federal University, Niterói, RJ, Brazil
Alícia Farinati, M.D., Ph.D. Faculty of Medicine, Universidad del Salvador, Buenos Aires,
Argentina
Priscilla Frauches Madureira de Faria, M.D. Fluminense Federal University, Niterói, RJ,
Brazil
Ronaldo Soares de Farias Nucleus of Tropical Medicine—DST Ambulatory Federal
University of Ceará, Fortaleza, CE, Brazil
Edison Natal Fedrizzi, M.D., Ph.D. Federal University of Santa Catarina, Florianópolis,
SC, Brazil
Contributors xv
M. Ferrer Gispert, M.D., Ph.D. Department of Obstetrics and Gynecology, Dexeus

Institute of Barcelona, Barcelona, Spain
Antônio Chambô Filho, M.D., Ph.D. Gynecology and Obstetrics of Santa Casa de
Misericórdia de Vitória, de Vitória, ES, Brazil
José Trindade Filho, M.D., M.Sc. Dermatology, Fluminense Federal University, Niterói,
RJ, Brazil
Juan Carlos Flichman Flichman Laboratory, Buenos Aires, Argentina
Nei Fialho, M.D. Gynecology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
Susana Cristina Aidé V. Fialho, M.D., Ph.D. Gynecology, Fluminense Federal University,
Cláudia C. de Garcia, M.D. Fluminense Federal University, Niterói, RJ, Brazil
Paulo Cesar Giraldo, M.D., Ph.D. Department of Obstetrics and Gynecology, Faculty of
Medical Sciences, State University of Campinas, São Paulo, Brazil
Philippe Godefroy, M.D., M.Sc. Federal University of Fluminense, Niterói, RJ, Brazil
Heloneida Studart Women’s Hospital, São João de Meriti, RJ, Brazil
Tegnus Vinicius Depes de Gouvêa, M.D., M.Sc. STD Sector, Fluminense Federal
University, Niterói, RJ, Brazil
Gesmar Volga Haddad Herdy, M.D., Ph.D. Pediatrics, Fluminense Federal University,
Ledy do Horto dos Santos Oliveira, Ph.D. Fluminense Federal University, Rio de Janeiro,
RJ, Brazil
Neiw Oliveira Iamada, M.D. STD Sector of Fluminense Federal University, Niterói, RJ,
Brazil
Tomaz Barbosa Isolan, M.D., M.Sc. Federal University of Pelotas, Pelotas, RS, Brazil
Sílvia Lima Farias, M.D. Brazilian Society of Pathology of Lower Genital Tract
and Colposcopy, Belém, PA, Brazil
Paulo Linhares, M.D. Laboratory Paulo Liñnares, Rio de Janeiro, RJ, Brazil
Camila Brandão Lobo, D.D.S., M.Sc. National Cancer Institute, Rio de Janeiro, RJ, Brazil
Helena Rodrigues Lopes, B.Sc., Ph.D. Fluminense Federal University, Niterói, RJ, Brazil
Ana Cristina Machado, M.D. Fluminense Federal University, Niterói, RJ, Brazil
Raimundo Diogo Machado, Ph.D. Federal University of Rio de Janeiro, Rio de Janeiro,
RJ, Brazil
Helder José Alves Machado, M.D. Hospital Orêncio de Freitas, Niterói, RJ, Brazil
Nísio Marcondes Pathology, Institute of Gynecology, Federal University of Rio de Janeiro,
RJ, Brazil
Bruno Pompeu Marques, M.D. Brazilian Society of Sexually Transmitted Diseases, São
Paulo, SP, Brazil
Renata Marques, M.D. Gynecology and Obstetrics, Hospital das Clinicas de Teresópolis,
RJ, Brazil
xvi Contributors
Francisco Massa, M.D. Municipal Health Department of Niterói, Attention Center for
Adolescence, Rio de Janeiro, RJ, Brazil
Roberto Maués Dermatology, Faculdade de Medicina Souza Marques, Rio de Janeiro, RJ,
Brazil
Flávio Merly, D.D.S. Integrated Nucleus of Stomatology, University of Grande Rio, Rio de
Janeiro, RJ, Brazil
Angelica Espinosa Miranda, M.D., Ph.D Department of Social Medicine, Federal
University of Espirito Santo, Vitória, ES, Brazil
Maurício Morelli M.D. STD Sector, Fluminense Federal University, Rio de Janeiro, RJ,
Brazil
Andréa Braga Moleri, D.D.S., M.Sc. Fluminense Federal University, Niterói, RJ, Brazil
University of Grande Rio, Rio de Janeiro, RJ, Brazil
João Soares Moreira, M.D., Ph.D. Hospital Evandro Chagas—Oswaldo Cruz Foundation,
Miriam Beatriz Jordão Moreira, D.D.S., M.Cs. Faculty of Dentistry, Fluminense Federal
Sandra F. Moreira da Silva, M.D., M.Sc. Infectious Diseases, Federal University of
Espírito Santo, Vitória, ES, Brazil
Sidney Nadal, M.D., Ph.D. Emilio Ribas Infectious Diseases Institute, São Paulo, SP,
Brazil
Sérgio Mancini Nicolau, M.D., Ph.D. Gynecology, Federal University of São Paulo, São
Paulo, SP, Brazil
René Garrido Neves Dermatology, Federal University of Rio de Janeiro and Universidade
Federal Fluminense, Niterói, RJ, Brazil
Ana Carolina Vitola Pasetto, M.D. Department of Obstetrics and Gynecology, University
Hospital, Federal University of Paraná, Curitiba, PR, Brazil
Felipe Dinau Leal Passos, B.Sc. Medical Academic of the Faculty of Medicine of Campos,
Mariana Dinau Leal Passos, M.D. Pérola Bylton Hospital, São Paulo, SP, Brazil
Márcia Soares Pinheiro, B.Sc., Ph.D. Fluminense Federal University, Niterói, RJ, Brazil
Paulo Cesar Vasconcelos Quintella, M.D. Surgical Clinics of the Municipal Hospital
Raphael de Paula Souza, Rio de Janeiro, RJ, Brazil
Renata de Queiroz Varella, M.D., M.Sc. Fluminense Federal University, Niterói, RJ,
Brazil
Helena Lucia Barroso dos Reis, M.D., M.Sc. Fluminense Federal University, Niterói, RJ,
Brazil
Adelaide Rodrigues STD Sector of Fluminense Federal University, Niterói, RJ, Brazil
Fábio Russomano, M.D., Ph.D. Instituto Fernandes Figueira—FIOCRUZ, Rio de Janeiro,
RJ, Brazil
Délcio Nacif Sarruf, M.D., D.D.S. Faculty of Dentistry, Fluminense Federal University,
Contributors xvii
José Carlos Saddy Saddy Diagnóstico, Niterói, RJ, Brazil

Pathology, Fluminense Federal University, Niterói, RJ, Brazil
José Carlos dos Santos Silva, R.N. Antonio Pedro University Hospital, Fluminense Federal
Paulo Roberto Nery da Silva, M.D. Medical Clinic Municipal Health Department of
José Carlos G. Sardinha, M.D. Alfredo da Matta Foundation, Manaus, AM, Brazil
Vandira Maria dos Santos Pinheiro, M.Sc. Fluminense Federal University, Niterói, RJ,
Brazil
Auri Vieira da Silva Nascimento, R.N. STD Sector of Fluminense Federal University,
Vera Lúcia Tenório Correia da Silva, M.D. Arthur Ramos Hospital, Maceió, AL, Brazil
Vânia Silami, M.D., Ph.D. Pathology, Fluminense Federal University, Niterói, RJ, Brazil
Renato de Souza Bravo, M.D., Ph.D. Fluminense Federal University, Niterói, RJ, Brazil
Roberto de Souza Salles, M.D., Ph.D. Virology, Fluminense Federal University, Niterói,
RJ, Brazil
Jussara Schwind Pedrosa Stussi Fluminense Federal University, Niterói, RJ, Brazil
Rogério Tavares, M.D. Fluminense Federal University, Niterói, RJ, Brazil
Sinésio Talhari, M.D., Ph.D. Dermatology, Federal University of Amazonas, Manaus, AM,
Brazil
Luiz Augusto Nunes Teixeira, M.D., Ph.D. Faculty of Medicine of Campos, Rio de
Janeiro, RJ, Brazil
Edson Gomes Tristão, M.D., Ph.D. Department of Tocoginecology, Federal University of
Paraná, Curitiba, PR, Brazil
Nelson Vespa Jr, M.D., M.Sc. Brazilian Cancer Control Institute, São Paulo, SP, Brazil
Altamiro Vianna Fluminense Federal University, Niterói, RJ, Brazil
Isabel Cristina Chulvis do Val Guimarães, M.D., Ph.D. Fluminense Federal University,
The Skin and Eruptives Lesions
1
1.1 Introduction 1.2 Skin Structure and Function (Fig. 1.1)
The skin is the largest organ of the human body, and corre- 1.2.1 Epidermis
sponds to 15% of the body’s weight. Although there are
topographical variations, it is composed of three basic struc- The epidermis is a stratified, keratinized, not vascularized
tures layered in the following order: hypodermis (subcutane- pavement epithelium of ectodermal origin. The epidermis
ous layer), dermis and epidermis. originates the following cutaneous attachments: piloseba-
This covering tissue that bounds the individual of his ceous follicle, sudoriparous glands, hair, and nails. Its main
environment has as vital functions the protection against functions are the relative impermeability, which prevents the
external aggressions, the maintenance of fluids in the body, free movement of fluids and molecules in both directions, the
and the thermoregulation, besides playing an important sen- protection from the entry of microorganisms, as well as from
sorial role. Due to its great accessibility to inspection, unlike excessive ultraviolet radiation and low-voltage electric
the viscera, the skin becomes one of the major components power.
of the physical beauty providing self-esteem and social coex- As it is not vascularized, the epidermis depends on the
istence. Frequently, aesthetic changes cause inferiority feel- supply of nutrients through the dermis, with which estab-
ings and unthinkable social discrimination to people for the lishes a relationship of interdependence.
rest of their lives. The dermis basic element is the keratinocyte, which dur-
This inspection easiness requires the knowledge of a ing its migration towards the surface undergoes a differentia-
number of skin changes related only to aesthetics, in order to tion process, whose goal is the production of keratin. When
differentiate them from those that actually bring harm to the keratinocyte reaches the surface, it is transmuted into an
health. inviable and anucleated cell full of keratin, which will then
The cutaneous integrity is fundamental so that the skin perform the main epidermic functions.
can properly put in practice its prevention function against The epidermis is divided into four cell extracts, character-
the access of toxic agents, microorganisms and excess of ized by degrees of its keratinocytes differentiation and mor-
ultraviolet radiation to the body, impede the loss of fluids, phology. The nearest layer to the dermis is the basal layer,
and protect against excess of temperature, mechanical forces following towards the surface the spinous extract, the granu-
and low-voltage electric current. lous and finally the corneal (Fig. 1.2).
© Springer International Publishing AG 2018 1

M.R.L. Passos (ed.), Atlas of Sexually Transmitted Diseases, https://doi.org/10.1007/978-3-319-57470-7_1
2 1 The Skin and Eruptives Lesions
Fig. 1.1 Skin Structure

and Function Hair
Sweat pore
Sebaceous
gland Free nerve ending
Meissner
crepuscle
Keratinized layer
Epidermis
Sweat
gland
Dermis
Erector muscle
of the hair
Subcutaneous
adipose tissue
Hair follicle Artery

Vein
Fig. 1.2 Epidermis Corneal Extract
Grainy Extract
Prickly Extract
Basal layer
Basement membrane
1.2 Skin Structure and Function 3
1.2.1.1 Basal or Germinative Layer protective functions of the epidermis. Although it is not
As the cornea’s cells are continuously removed, the mainte- completely impermeable, it is an excellent barrier to the
nance of the epidermis depends on a permanent replacement movement of fluids, molecules and microorganisms, and
of new cells. This replacement is promoted by the keratino- any damage to its integrity harms this function extremely.
cytes mitosis of the basal layer, which are little differentiated, Its low water content is the unique and exclusive feature
and retain proliferative capacity. The basal layer is composed that raises difficulties to the establishment of microorgan-
of a single layer of cylindrical cells, with the largest axis per- isms on the surface of the skin.
pendicular to the dermoepidermal junction. In normal skin, The epidermic extracellular space is extremely imperme-
around 10% of the basal cells are in mitosis. At any given able, allowing the nutrition of all epidermic layers, except the
time this percentage could increase depending on the physi- corneal extract. A water-soluble barrier is located in the
ological (repair) or pathological (e.g., psoriasis) needs. boundary between the granulous and the corneal extract. This
barrier is probably responsible for the abrupt transformation
1.2.1.2 Spinous Extract of the viable cornified cells in not viable ones, because it dis-
It consists of several layers of polygonal keratinocytes under ables the nutritional supply to those cells located above it.
differentiation process. These are rich in cytoplasmic tonofila- The impermeable property of this region appears to be caused
ments, grouped more compactly, as the cell progresses toward by two factors: a special substance secreted at this level and
the surface. These tonofilaments are the precursors of keratin. represented by Odland bodies or lamellar bodies, and a type
of intercellular contact found only there, named zonula
1.2.1.3 Granulous Extract occludens, in which there is an intimate union between the
It consists of variables layers of flattened keratinocytes con- adjacent cytoplasmic membranes.
taining granules of keratohyalin associated with cytoplasmic There are still two other specialized types of epidermal
tonofilaments. These granules seem to contribute to the for- intercellular contact: the gap junction and the desmosome.
mation of the cytoplasmic matrix of corneal cells. The gap junction sets a free traffic corridor between the
adjacent cells and plays an important role in the differentia-
1.2.1.4 Corneal Extract tion of the epidermis as a whole; only missing in the corneal
It consists of 8–15 layers of flattened anucleated keratino- extract.
cytes. The cytoplasm is completely filled with a very resis- The demosomes are the main and most numerous types of
tant and insoluble fibrous protein called keratin. epidermal intercellular contact. They occur in all layers, pro-
As it is the final product of the keracinocyte differen- viding stability to the tissue. The hemidesmosomes occur
tiation, the corneal extract is the main responsible for the between the basal cells and the basal lamina (Fig. 1.3).
Fig. 1.3 Epidermal

intercellular contacts
Occludens zone Slot joint Desmosome

1.2.1.5 Dermoepidermic Junction and the dermis, the anchoring fibrils and microfibrills
The dermoepidermic junction corresponds to the basal mem- (Fig. 1.4).
brane in the optical microscopy. The electronic microscopy The basal lamina has the following functions: ensure the
is a complex structure comprising the cytoplasmic mem- dermoepidermic adherence, guide the migratory direction
brane of the basal cells, the lucid blade (empty space), the of keratinocytes to the surface and work as a system of
basal lamina and the most superficial portion of the papillary pores of different sizes, allowing the quick passage of small
dermis. Promoting adhesion between the basal cells and the molecules and making difficult the passage of larger
basal lamina, are the hemidesmosomes, and between this molecules.
Fig. 1.4 Dermoepidermal

Basal cells
junction
Lucid blade
Basal blade
Anchoring braces
1.2 Skin Structure and Function 5
1.2.1.6 Other Epidermic Cellular Components by invagination of the keratinocytes. In the hair follicle ends
Non-keratinocytes cells of the epidermis are called clear the sebaceous gland duct, and in certain regions (axilla and
cells, as they require special coloring to become evident. We genital region) the duct of the apocrine sweat glands also. All
will consider the melanocyte, the Langerhans cell and the these structures are located in the deep dermis.
Merkel cell. The hair presents three cyclical and permanent stages:
anagen, catagen and telogen, corresponding respectively to
Melanocyte growth, regression and resting of the follicle. The growth
The melanocyte is a dendritic cell of neural crest origin (neuro- speed varies according to different parts of the body.
ectodermal) located between cells in the basal layer in an approx- Much more than the aesthetic and the sensorial function,
imate proportion of one melanocyte to ten keratinocytes. the hair is important for the protection from solar radiation,
Its function is the synthesis of melanin obtained by the thermal homeostasis and tissue repair, acting as true reser-
action of the enzyme tyrosinase on tyrosine. Melanin is voir of epidermal stem cells.
stored in rounded cytoplasmic structures, the melanosomes,
which are transferred to the adjacent keratinocytes via Sebaceous Gland
phagocytosis of dendritic cytoplasmic portions. Thus, the This gland originates in a protuberance of the hair follicle.
melanocyte functions as a unicellular exocrine gland. Vary in number, size, and activity in the parts of the body.
Melanin is a brown pigment with photoprotection action. Under action of testosterone becomes active from puberty.
Racial variations of skin color depends on the quantity, size Their secretion (sebum) is basically composed of liquids,
and morphology of the melanosome produced, as the melano- which, together with the lipids derived from the corneal
cytes number and the melanin quality are basically the same. layer, will form the lipid mantle, which is a factor of imper-
The exposure to ultraviolet radiation increases the pro- meability (hydrophobic) and antisepticing.
duction of melanosome and its transference to the keratino-
cytes, causing skin pigmentation and providing greater Apocrine Sebaceous Gland
protection against future exposures. White skins are more Derives from the same invagination germinal layer, which
susceptible to harmful immediate action (burning) and late gives rise to the hair follicle. It is an androgen-dependent
action (elastosis, keratosis, epitheliomas, melanomas) of this scent gland present only in the axillary, genital and periareo-
radiation. lar areas, whose secretion is metabolized by the skin sapro-
Melanocytes are still susceptible to MSH (Melanocyte phytic bacteria, producing characteristic odour that functions
Stimulating Hormone), as well as to sex hormones, to inflam- as a social and sexual attraction.
matory agents and to vitamin D produced in the epidermis.
Erector Hair Muscle
Langerhans Cell Smooth muscle positioned at the top of the dermis inside the
Is a dendritic cell situated in the basal and granulous layers, hair follicle.
containing cytoplasmic granules in the form of a racket. Also
originated in the bone marrow, performs an important Eccrine Sudoriparous Glands
immune function, presenting the antigen to dermal These glands, formed by epidermal sprouting, are distributed
lymphocytes. throughout the skin. The greater concentrations areas are
located in the palmoplantar regions. They are located in the
Merkel Cell deep dermis and flow directly on the surface of the skin.
It is found in the basal layer of the skin of the fingers, lips, Their number varies from two to four million, and its total
gums and palate, playing a mechanoreceptor sensorial mass is equivalent to a kidney’s. An individual can secrete up
function. to 10 L of sweat per day.
Its basic and vital function is the thermoregulation
1.2.1.7 Cuttaneous Attachments obtained through the sweat evaporation with the consequent
cooling of the cutaneous surface.
Pilosebaceous Follicle The composition of the secretion includes water, sodium,
Structure formed by the hair follicle, sebaceous gland, and calcium, magnesium, iodine, phosphorus, sulfur, iron, zinc,
hair erection muscle. manganese, mercury, urea, amino acids, albumin, types
IgA, IgG and IgD alfa globulins and immunoglobulins.
Hair Follicle However, the serum metabolites depuration is fully held by
The hair follicle is distributed throughout the skin except in the kidneys and is not considered a vital function of these
the palmoplantar regions. It is formed in the embryonic life glands.
1.2.2 Dermis 1.3 Dematological Diagnosis
The dermis is a soft connective tissue, richly vascularised The great difficulty of the dermatological diagnosis arises
and innervated. The cellular elements of the normal dermis from the small number of possible clinics manifestations
are the following: fibroblasts (dermal fibres’ producers), due to a wide variety of pathological conditions. However,
mast cells, histiocytes, dendritic cells and a small number of an accurate analysis of the individual lesions, the arrange-
lymphocytes. The extracellular matrix is composed of fiber ment between them, its distribution through the integu-
proteins (collagen and elastic fibers) and the essential sub- ment associated with systemic manifestations and history,
stance (proteoglycans). are often enough to the correct diagnostic conclusion.
It is divided into papillary dermis or superficial (composed of When it does not occur, we make use of the laboratory
thin collagen fibers arranged vertically), deep or reticular (thick resources.
collagen fibers, grouped in dense bundles horizontally com- The dermatological exam training is like learning to read,
pressed), and adventitial (around vessels and attachments). and depends on basic theoretical knowledge and a lot of
The dermis performs a protection function against practice.
mechanical aggressions due to its viscoelastic property, pro- The dermatological examination routine must always
viding the resistance to tensions and pressures, and becom- obey the following anamnesis rules: patient identification
ing recomposed after these movements. Due to this vascular (full name, age or date of birth, color, marital status, birth-
power, it plays an important thermoregulatory role. It has a place, and occupation), main complaint, history of present
close relationship with the epidermis, suppressing its nutri- illness, past medical history (including drugs of regular or
tional, hormonal, nervous factors, and others. sporadic use), physiological and pathological history, family
background and social history (and also considering condi-
tions of housing, travelling, etc.).
1.2.3 Hypodermis Starting with the observation of the general state of the
patient, the examination of the skin, mucous membranes and
The subcutaneous tissue, or hypodermis, is composed of adi- nails, carried out with the patient preferably entirely naked
pocytes’ lobules, limited by septa of collagen fibers, which and under good light conditions. At first, the patient should
accommodate vessels and nerves. It performs protections be inspected at some distance, and considered the distribu-
functions against mechanical force (pressure) and loss of tion of injuries and extension of the manifestation; subse-
heat as well, besides storing calories. quently examination of the injuries in detail, the type of the
lesion, its color, shape and size, arrangement, distribution,
and finally, palpation of the consistency, temperature and
1.2.4 Nails humidity.
After the physical examination, we can retake the history
Nails are cytokeratin structures covering the distal phalan- of the present or pathological disease, and with a diagnostic
ges, originated in the nail matrix. Other nails components are suspicion already formed, treat it. The following must be
the following: eponychium, nail plate, nail bed and hypo- necessarily questioned: time and evolution of the disease,
nychium. Their main function is to protect the ends of the subjective symptoms (pruritus, pain sensitivity, etc.), drugs
fingers and toes against traumas, keeping the touch of the used, description of the initial injury, triggering or aggravat-
fingers. It also plays an important role in aesthetics of the ing factors and systemic symptoms.
hands and feet, particularly for women. Finally, we can use semiology (sensitivity test, etc.) and
It is a structure of several changes caused by local and laboratory resources, such as specific dermatology proce-
systemic diseases, sometimes assisting in the diagnosis dures (dermatoscopy, biopsy, microbiology, etc.), and the
conclusion. usual (CBC, etc.).
1.3 Dematological Diagnosis 7
1.3.1 Dermatologic Semiology • Cyanosis: purple, reduced hemoglobin, conse-

quent to the venous congestion.
The eruptive elements, or cutaneous efflorescence, or ele- • Enanthema: erythema located in the mucous
mentary lesions can be classified according to the type of membranes.
injury, shape, arrangement and distribution. • Exanthema: generalized erythem.
• Erythrodermia: universal erythema involving all
1.3.1.1 According to Type of Lesion the skin and often accompanied by exfoliation.
Several classifications of the eruptive elements have already (b) Permanent Vascular Stain
been identified. The most used are the Schulmann’s with • Angioma: red, flat, disappears through vitropres-
some changes, as it is didactic and easy to understand. sure, caused by vascular neoformation.
We can group them into six types, as follows: • Anemic Nevus: permanent pale.
• Telangiectasia: linear, capillary vasodilation.
–– Color-changing lesions. (c) Blood Stains
–– Solid lesions. Also called purpura, occurs by extravasation of vases
–– Liquid content lesions. erythrocytes of reddish-violet to purple colour, does
–– Lesion with cutaneous thickness change. not disappears through vitropressure.
–– Lesions with continuity solutions. • Petechiae: pinpoint.
–– Senile lesions. • Wound: bigger, in sheet.
• Víbice: linear.
Color-Changing Lesions (Fig. 1.5) (d) Pigmentary Stains
It is an exclusive change of the skin color, without the modi- Naturaly related to the concentration of melanin in
fication in the relief or in the consistency of the skin. When the skin. However, it may occur due to the deposi-
the change is limited to an area it is called macula or stain, tion of other endogenous pigments (e.g. bilirubin)
and receives various names when the process is widespread. or exogenous (e.g. carotene, tattoo, etc.), causing
different colorations related to the provocative
1. Stain element.
The origin can be vascular, transitory or permanent, or by • Hypocromic: whitish due to melanin reduction.
pigment deposition. • Achromic: porcelain-like, melanin absence.
(a) Transitory Vascular Stains • Hypercromic: excess of melanin or other pigment.
• Erythema: various shades of red due to vasodilata-
tion. Characteristically disappears through vitro
pressure. There are several subtypes:
Fig. 1.5 Eruptive lesion with color change—erythematous spots

(syphilitic roseola)
Solid Lesions (e) Gumma

• Nodule that evolves with infiltration, softening, fistu-
(a) Papule Fig. 1.6 lization, ulceration and scarring.
• Smaller than 1 cm. (f) Vegetation/Condylomatous (Fig. 1.8)
(b) Plaque • Papule or plaque consisting of small, multiple and
• Less than 1 cm, with a diameter greater than 1 cm. grouped elevations.
Often it is a consequence of the confluence of (g) Urtiga (seropapule)
papules. • It is the typical lesion of urticaria, consequent to der-
(c) Nodule (Fig. 1.7) mal edema, high, flat and characteristically evanes-
• May show or not important changes of the protuber- cent, disappearing in a few hours.
ance, in general more palpable than visible, limited, (h) Verrucosity (Fig. 1.9)
with a diameter between 1 and 3 cm. • Papule or plaque with hardened surface due to the
(d) Nodosity or Tumor peculiar increase of the corneal layer.
• Limited, with changes of the protuberance or not, (i) Tubercle
bigger than 3 cm in diameter. Normally used for neo- • Papule or nodule, which usually progresses and
plastic lesions. leaves a scar.
Fig. 1.8 Eruptive lesion, solid lesions, vegetation/condylomatous

aspect (flat condyloma, secondary syphilis)
Fig. 1.6 Eruptive lesion, solid lesions—papule (secondary syphilitic)
Fig. 1.7 Solid eruptive lesion, nodule (cystic inclusion)

Liquid Content Lesions
(a) Vesicles (Fig. 1.10)

• Liquid accumulation up to 0.5 cm in diameter.
(b) Bubble
• Liquid accumulation over 0.5 cm in diameter.
(c) Pustule (Fig. 1.11)
• Superficial purulent accumulation smaller than
0.5 cm in diameter.
(d) Abscess (Fig. 1.12)
• Deep purulent accumulation.
(e) Hematoma
• Blood accumulation.
Fig. 1.9 Eruptive lesion, solid lesions, verrucous aspect(condyloma

acuminata— HPV)
Fig. 1.10 Eruptive lesion of liquid content, vesicles (genital herpes)

Lesions with Cutaneous Thickness Change
(a) Keratosis
• Thickness due to the increase of the corneal layer,
dense and inelastic.
(b) Lichenification
• Increase of epidermal thickness with accentuation of
the skin grooves.
(c) Infiltration (Fig. 1.13)
• Resulting from the dermal cell infiltrate, presents
increase of the skin consistency with a decrease of its
natural groove.
(d) Esclerosis
• Increase of skin consistency, which becomes inelastic
due to collagen changes.
Fig. 1.11 Eruptive lesion of liquid content, pustule (genital herpes)
(e) Atrophy (Fig. 1.14)
• Can be epidermic, dermic, or hypodermic; it the first
one, the epidermis is thin and transparent, while in
the others there is a depression of the skin.
(f) Scar
• Residual element of a pathological process. May be
atrophic, hypertrophic, or keloidal, where grooves,
pores and hair are absent.
Fig. 1.12 Eruptive lesion of liquid content, abscess (lymphogranuloma

venereum)
Fig. 1.13 Eruptive lesion with changes in cutaneous thickness, infiltra-

tion (swelling in vulvitis due to candidiasis)
Fig. 1.14 Eruptive lesion with changes in cutaneous thickness, atro-

phic scar (donovanosis sequel)
Fig. 1.16 Eruptive element, solution of continuity, ulcer (chancroid)
Lesions with Continuity Solutions
(a) Excoriation
• Loss of epidermis only.
(b) Erosion or Exulceration (Fig. 1.15)
• The loss of substance affects the papillary dermis.
(c) Ulceration (Fig. 1.16)
• Loss of substance besides the papillary dermis. The
characteristics of its locations and borders (regularity,
color, elevation) must be observed, as well as the base
consistency, bottom (grainy, purulent, necrotic), pain
and associated changes (varices, nodules, sensitivity,
etc.).
(d) Fissures or Rhagades (Fig. 1.17)
• Consists of the solution of the continuity of the linear
Fig. 1.17 Eruptive element, solution of continuity, fissures (after
format skin, usually around the natural holes. inflammatory process due to candidiasis
(e) Fistula (Fig. 1.18)
• Ulcerous path that drains a deep focus.
Fig. 1.15 Eruptive lesion, solution of continuity, erosion (genital Fig. 1.18 Eruptive lesion, continuity solution, fistula (lymphogranu-
herpes) loma venereum)
Senile Lesions (c) Eschar

• Black colored skin segment, resulting in tissue
(a) Scale necrosis.
• Deriving from changes in the keratinization, corre-
sponding to an abnormal corneal layer exfoliation. Normally the eruptive elements compose different combi-
(b) Crusts (Fig. 1.19) nations, allowing several expressions: papular erythema,
• Concretions resulting from draining of exudates of papulonodular, atrophic squamous, crusted ulcers, vesicu-
the cutaneous surface, blood or pus. lobullous, etc.
Fig. 1.19 Eruptive lesion,

crusts (genital herpes in HIV
[+] patient)
1.3.1.2 Shape and Disposition of the Lesions Lesions Distribution

Each lesion, individually or together, frequently takes spe- The distribution of the lesions by the integument is the third
cial configurations, which can be very important to the component of the semiotic dermatologic triad, and often the
diagnosis. elucidative diagnostic.
Annular—ring. The lesions may be localized, regional or widespread.
Arciform—bow. The term “universal” is used when there is an involvement of
Circinate—circular. the entire extension of the skin, hair and nails.
Corymboid—central grouping of dense lesions, sur- The following data should be taken into account due to
rounded by sparse satellite lesions (similar to an explosion). their importance:
Discoid—disk shape.
On target—concentric circles. –– Symmetry: symmetric lesions are generally of endoge-
Gyrate—turnings. nous origin (e.g. virchowian hanseniasis).
Guttate—drops. –– Preferred areas: for example, areas exposed to sunlight
Herpetiformis—grouped in clusters. (e.g., photodermatoses).
Lenticular—lens. –– Intertriginous areas: chafing of adjacent areas (e.g., inter-
Linear—line. trigo, candidiasis etc.).
Miliary—grain. –– Contact areas in the shape of certain objects (e.g., contact
Nummular—coin. eczema).
Punctate—dots. –– Preferred areas of pathological condition (e.g., hard
Reticulated—net. chancre).
Serpiginous—sinuous.
Zosteriform—on the path of a nerve. Even when the manifestation is widespread, as in second-
ary syphilis, the involvement of certain regions (palmoplan-
tar, oral mucosa) can assist in the differential diagnosis (e.g.,
skin reaction to drugs or pharmaco-dermia).
Syphilis
2
2.1 Synonymy • 21–30 days: Hard or inoculation chancre—a single lesion

(and in rare cases multiple) with hardened edges as a
Lues, chancre, protosyphiloma. result of lymphoplasmacytic inflammation. This lesion is
more commonly visible in men, in the balanopreputial
groove, than in women. If the chancre is left untreated it
2.2 Concept can persist for 30–90 days, after which it involutes spon-
taneously. In women, vulval lesions can be observed in
Syphilis is a chronic and systemic infectious disease that is rare cases.
transmitted sexually or via other intimate contact. It may be • 30 days: Satellite adenopathy—bilateral (inguinal), pain-
transmitted from mother to fetus (intrauterine) or through less and uninflamed. The chancre and satellite adenopa-
contact between mother and child during birth. thy are known as primary syphilis.
Data from the World Health Organization (WHO) esti- • 30–40 days: Seropositive results are obtained.
mates that around ten million new cases of this disease are • 50–180 days: Macular and papular exanthematous legions
reported each year. on the skin and/or genital or oral mucosa. Treponema
enters the circulation and multiplies, causing the exan-
thematous stage (roseola) to spread across the body.
2.3 Incubation Period Macular and papular lesions with a range of clinical
appearances then appear (syphilids). This phase is also
The incubation period is from 21 to 30 days after contact known as secondary syphilis. All of these lesions involute
with an infectious agent. This can vary from 10 to 90 days, spontaneously without leaving sequelae, even in the
however, depends on the number and virulence of the infect- absence of treatment. As a there are a wide variety of pos-
ing bacteria and the immune response of the individual. sible lesions, it is worth considering any genital lesion to
be syphilitic.
2.4 Etiologic Agent
Treponema pallidum, subspecies pallidum. This is a Gram- 2.5.2 Latent Syphilis

negative spirochete that does not grow in artificial media. It
is sensitive to heat, detergents and common antiseptics and This occurs 1–2 years after infection. It is known as the
has difficulty surviving in dry environments. It is an exclu- “clinically silent” stage, and may only be diagnosed via sero-
sively human pathogen. logical screening.
This stage is divided into early (up to 1 year) and late.
2.5 Clinical Presentation

2.5.3 Late Syphilis
2.5.1 Early Syphilis
This may start at the end of the latent phase or many years
Development of lesions: afterwards. Its clinical presentations are divided into:
© Springer International Publishing AG 2018 15

M.R.L. Passos (ed.), Atlas of Sexually Transmitted Diseases, https://doi.org/10.1007/978-3-319-57470-7_2
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evening; I was afraid your mother was not able so you could come.”
“She is some better. She thinks and wished me to come, as she says I have
stayed at home very much of late on her account. I shall not stay very long
tonight, as I think she did not feel as well as usual.”
The young men went out on the piazza and were viewing the scenery by
moonlight, when who should they espy but Minnie and Ralph coming towards
them.
As they came up to them Minnie said, “Why brother, where is cousin?”
“She is with mother. I came to find you. Where have you been all this time?”
“You could not have looked very sharply, or you would have found me, as we
have been following you for some time and wondering where cousin was,” said
Minnie.
“Come, Mr. Burton, we will go and find her,” said Warren, leading the way
through the company to where Nettie and her aunt sat chatting pleasantly.
As they came to them Paul said, “Miss Spaulding, please favor me with your
company for a waltz?”
“Please excuse me, I never dance,” said Nettie, smiling.
“We will promenade then, if you wish. I do not care to dance either,” answered
Paul.
She took his arm, and as they walked along comments of praise were lavished
upon them, as they made a splendid-looking couple; and many of the company
saw at a glance that the young man loved to be in the company of the strange
young lady; and many a young lady there knew that he loved to dance, but
preferred the company of the lady by his side. Many envious glances were
given Nettie that evening, but she appeared not to notice them. She used them
all alike, and, when not in company with Paul, she would seek the company of
her aunt and uncle and look on and see the others enjoy themselves. “I do not
care to dance,” she would tell all who asked for her company. “I cannot enjoy
dancing,” she would say to her aunt, when she urged her to dance.
“No, no, I can not,” she would say.
It was not because she could not dance. It was because of a request of her
father, who was lying in his grave, and of her mother who was far away at
home.
How many young people of today scarcely wait till the green sod grows over
the grave of some beloved form, before they are away to some ball or place of
amusement? Such is progression.
It was getting quite late and Paul came to Nettie and said, “Miss Spaulding,
accept my company, please, for a promenade on the piazza. The moon is
spreading its rays beautifully and the evening is delightful.”
She took his arm and they walked quietly out under the trailing vines of
myrtle, which were trained to droop from the eaves of the old farm-house.
They came to an old-fashioned settee that was enfolded in the drooping vines
and formed an arbor. Here they sat down. Soon Paul said, “Miss Spaulding,
have you been down to the lake since Monday?”
His companion blushed deeply as she answered. “I have not, sir; you must
have heard all I said, did you not? I was very lonely that day—my poor mother
far away and I alone here. My cousins are very kind to me, very kind indeed, or
I do not know what I should do.”
“Will you accept the friendship of a stranger? As you know but little about me
that is all I will ask now. I never saw a lady in all my wanderings who ever drew
such words of acknowledgment from me before. All I ask is friendship, and
when you know me better perhaps I shall ask you for this little hand.”
He gently raised her hand to his lips as he was speaking.
She drew it quickly from him saying: “Sir, please pardon me if I have given you
occasion to make the declaration. The truth we should tell at all times; perhaps
you think me rich; if so, you are mistaken. I am very poor. Such as you needs
not the friendship of one beneath him.”
Truth and honesty shone in her dark, brown eyes as she turned her head away
to hide the gathering tears. It pained her very much to tell him whom she
loved. She had been taught to shun deceitfulness, and she thought it decisively
her duty to tell him she was poor, no matter how it pained her to do so. She
spoke deliberately, but in a dejected manner. She was pale, with a faint flush on
her cheeks that was drawn there by the enthusiasm she was forced to exercise.
“Nettie, darling, you do not know me. It is not wealth I wish. It is this little
being by my side. She is rich in voice, rich in beauty, and richer still in mind.
Do not say wealth to me again—it hurts my feelings.”
As he spoke he gently drew the little form nearer to him and rested her head
on his great, manly breast.
“Only four days have I known you, yet it seems to me a life time.”
Nettie quickly arose saying: “Please, sir, say no more to me; always remember
me as your true friend, one who will not do you an unkindness. Never say
aught of this meeting to anyone for my sake and for yours, and in the future if
you prove faithful to me I am yours.”
She turned and fled away, leaving him sitting in the twilight deeply touched.
How long he had been there he knew not. Warren Hilton’s voice brought him
to his senses as he said, “Paul, where is my cousin? I have not seen her since
you came out together.”
“Oh, Warren! I do not know; she abruptly left me here, and how long I have
been here I know not. Oh, I have stayed too long. I must surely go home.”
He quickly arose, and he looked so sad Warren really pitied him as he said,
“Why, Paul, are you sick?”
“Oh, no,” answered Paul; “only sorry I have stayed from home so long.”
“I hope you have not been unkind to my little cousin,” said Warren changing
the subject, as he thought Paul was really thinking of his mother.
“Been unkind to her? been unkind to your cousin?” said Paul, looking Warren
squarely in the face; “I would sooner cut my right hand off than say one word
to offend that lovely little girl.”
Warren saw he was deeply troubled as he answered, “Paul, what then is the
matter?”
“I cannot tell you; go find your cousin. Perhaps she will tell you.”
Paul’s voice trembled, and Warren readily guessed the cause, as he thought
Paul had sued for the hand of his cousin and had been refused. He went to
find Nettie and he thought she would readily tell him all he wished to know.
He looked, but could not find her anywhere among the company. At last he
found Minnie and asked her where Nettie was.
“I have not seen her for a long time; I saw her last with Mr. Burton.”
“She is not with him now and has not been for some time. I wish you would
go up to her room and see if she is there,” said Warren, “I fear something is
the matter with her.”
Minnie ran softly upstairs to her room. She heard someone walking to and fro
as if in a hurry. She gently rapped at the door and a trembling voice bid her
come in.
“You know you are always welcome, Minnie.”
Not heeding Nettie’s words Minnie said, “why did you come up here? Warren
missed you and sent me to find you. Why, Nettie, where are you going? I see
you have been packing your trunk.”
CHAPTER IV.
“I hope you are not going home?”

“Yes, cousin, I shall go tomorrow. I wish you would bear the intelligence to
your father and mother and entreat them to let Cousin Warren take me to the
village in time to take the coach for home tomorrow. I do not care to ask him,
as he will question me. Mother will be looking for me in a day or so and I
concluded to go tomorrow.”
She gave her hand to her cousin, saying: “We will go down to the hall now or
the company may think it strange we are both gone.”
They went along the corridor as placidly as if nothing had transpired to mar
the pleasure of the evening.
They came to where Warren stood toying with the tassel of the window
curtain and looking out into the moonlight with deeply-troubled thoughts.
“Where have you been, you little rogue? we have been looking for you for
some time.”
“She has been packing her trunk to go home tomorrow morning: I cannot get
her to stay any longer,” said Minnie.
“What has caused you to make such a quick decision? I supposed you were
going to stay with us two or three weeks. Something has offended you I fear,
or you would not decide so quickly to go home.”
“No, Warren, nothing has happened of any account: please don’t scold me,”
said Nettie sorrowfully, as she was nearly overcome with the burden on her
mind.
She turned her head away to hide the tears from prying eyes. She turned to go
when Warren said, “Please excuse my last words, cousin, I did not wish to
scold you. See! yonder comes Mr. Burton. He is coming this way.”
He was calm but pale. As he drew near to them he said, “Mr. Hilton, get my
hat please; it is time for me to be going.”
As Warren left to do his bidding Paul said, “Miss Spaulding, if I have said
aught to offend you, pardon me. As God is my witness, what I have told you is
the truth. I will do as you have bidden me to do, and I ask in return to
remember me some times when alone.”
He gently pressed the little hand he was holding.
“Goodbye, and may God bless you forever,” said Paul solemnly.
Soon Warren came with the hat, and Paul taking it bid them all good night and
went homeward in a sad frame of mind.
One hope she had given him, viz: “If you prove faithful to me in the future I
am yours.”
These words cheered him, and he fully resolved to be true to her until death.
“What can be her object. Can it be she thinks she is not good enough for me
financially?” thus murmured Paul until he reached home.
He found his mother sitting up. She had been having a serious spell of heart
disease and dared not lie down. As he entered the room she was sitting in she
said, “My son, why did you come so soon? I did not expect you for some time
yet.”
“It is nearly twelve, mother, and I am sorry I stayed so long. You have been
sick, and are now, only wishing to keep me in ignorance of how bad you really
are. You look very ill mother. Why do you sit up so long?” asked her son,
bending over her and pressing a kiss on her fair brow.
“My son,” answered his mother, “I have the heart disease, and I fear you will
soon have no mother. I see it is growing worse with me with every attack, as I
cannot lie down after one now.”
“Oh! mother, do not speak so sadly. Shall I go for a doctor tonight?”
“It would do me no good. I have tried the best-skilled physicians there are on
the continent and they unite in saying I must be kept quiet or I will some day
be no more. I have prayed that I might live to see you grown to manhood, and
that prayer is answered and now I am willing to go when God sees fit to call
me.”
His mother was speaking in a sorrowful tone. Paul sat like a statue, pale as
death.
“Oh! mother, it cannot be,” he spoke at last. “I can not part with you; you who
are all the companion I have on earth,” answered Paul in frightened tones.
“My son you will not miss me much when you catch that ‘little human fish’
you spoke of the other day. Oh! if you should marry her I pray she may prove
a true, honest wife to you. Then you will lead a happy life.”
“Oh, mother, may your last few words be true! Time works wonders in this
world sometimes. I hope you may live long with me, then you will see what a
dutiful son you have,” answered Paul, the tears falling thick and fast.
The nurse came in with a cup of strong tea for his mother, and Paul arose as
he said, “Take good care of my mother and I will repay you well.”
He kissed his mother again and went off to bed but not to sleep. Try as he
might no sleep came to his eyes. Early the next morning he arose, took his
shot gun and went out to see if he could kill a pheasant, to make some broth
for his mother.
The next morning after the party Mr. Hilton said to his niece as she came
down to breakfast: “You did not receive much pleasure by the party I fear,
Nettie. Warren has been telling me you wish to start for home this morning. I
hope my children have not done anything to mar your pleasure here.”
“Uncle, they have done nothing to mar my happiness,” answered Nettie, with a
dreary laugh that touched her uncle’s heart.
“Will you promise me if you and your mother ever come to want that you will
come and live with us? Our house is large and you are both welcome to its
shelter.”
Nettie went gently to him, planted a kiss on his fair, honest forehead and said,
“I promise. Never can I forget the kindness I have received at this new home,
or forget the inmates that dwell here.”
The eyes of all of her friends were filled with tears to see the sweet young girl,
who, standing smoothing her uncle’s silvery hair, was outwardly calm, but a
deep trouble was raging in her breast, as she wished to stay but could not and
did not wish to let any of her friends know the real cause.
Her aunt said, “My dear, something has transpired to make you decide so
quickly to go home. We expected you were going to remain two or three weeks
with us.”
“Nothing, auntie, only my conception to go home and surprise mamma. She
will be very delighted to hear from you all. Of course I shall tell her what a
pleasant time I have had with my cousins. It is getting late and we should be
going soon or we will not be in time to take the stage, as it leaves at ten.” So
saying she began putting on her mantle and cap. As her cousin Warren drove
up to the door with a splendid span of iron grays, he called out lightly, “All
aboard for town.”
“Auntie, are you and cousin Minnie not going to see me off for home?”
“No, my dear, we cannot go with you, as we have these rooms to make tidy.
Warren will see you safe there and in the coach, too.”
Nettie bade her friends good-bye and was still lingering at the door, as she was
loath to leave her new found home.
“I will come back here some day perhaps, and then I will stay longer; or long
enough to make you wish there never more could come a Nettie Spaulding to
trouble you,” said Nettie, feigning a laugh.
“Never you need be afraid of that,” answered her uncle, “come and see us and
stay as long as ever you can. We will be most happy to see you.”
“Thank you, uncle, I will return soon no doubt.”
She tripped lightly out, and Warren handed her into the buggy, and soon the
two cousins went from that farmhouse in a very sad mood, as Nettie was
leaving her new found friends to go back to the great busy city to live within
herself, as her old associates avoided her, or she avoided them, as she could
not meet them as of old.
Warren was sad, as he did not wish his little cousin to leave them. She was like
a sunbeam in the dear old home, and he had taken great pleasure in getting the
two young people together who he thought were best suited to each other.
Now his pleasures were ended, as his cousin was going home.
“If she was not my cousin,” he would say to himself, “I would try to win her
affections, but that word cousin casts all into oblivion as far as I am
concerned.”
As they were driving over the rough country roads, Warren said, “Little cousin,
there is something wrong or you would not be leaving us so soon; is there
not?”
“Warren,” she said, bursting into tears, “God alone knows the misery I have
endured since last evening. You say you are my friend; I believe you, as you
seem to take great interest in my welfare. I am going home to live like a
hermit, in a great city. As such always think of me. I would like to stay, but it
can not be,” she exclaimed passionately.
“He is rich and I am poor. I can not stay and be a temptation to one who is
dearer to me than life. If he proves true then all is well, if not, then God pity
me.”
Warren was listening to her passionate words, while tears stood in his honest
blue eyes as he said, “Paul Burton is a man of honor. If he told my little cousin
he loved her it is the truth, as I have known him for many years, or ever since I
can remember a playmate, and I never have caught him in a lie.”
Nettie was weeping violently as she said, “Please write to me often, and write
all the news about him, but do not tell him one word about me. If he really
loves me he will find me, if not, it is better as it is.”
She spoke sadly.
“I will do as you have bidden me,” said Warren, “and prove to you that I am a
true friend.”
Suddenly the crack of a gun was heard. The horses sprang forward and nearly
threw the young couple out of the buggy.
“I wonder who is out sporting so early this morning,” said Nettie.
“It sounds like Paul’s gun,” said Warren, as he gently drew up the reins of the
horses and brought them to a walk.
“I wonder how Paul’s mother is this morning. He said she was not very well
last night. Perhaps he is out to kill something for her.”
“Has his mother been sick very long?” asked Nettie.
“She is a tall, frail woman, and she has very bad spells. Some people say she
has heart disease,” said Warren.
“I am very sorry indeed. It would be very sad for him to have his mother
taken from him. I really hope to hear when you write that she is better.”
They went slowly up to the little village hotel. The stage was about to start.
As Warren handed her down he said, “Do not forget to write me all your
troubles, cousin, and I will write you the news. I will give the same injunction
to come and live with us as father did.”
“Thank you for your kindness. I shall never forget you or the dear ones I left
in my new home by the lake,” answered Nettie.
“Have you no word for Paul?”
“Yes, cousin, tell him good bye, to be upright and honest in all his endeavors,
and God will deal justly by him. Good bye, cousin,” said Nettie.
As she took a seat in the stage she peeped out of the window and said, “Write
me often, and please send me the village newspaper if you do not think I am
asking too much. I will send the change when I arrive home.”
“I will go and order it sent you so you will get it next week,” said Warren.
The stage started on its long journey to the city, bearing one sad little being on
her way for home.
How happy it makes one feel to unburden a troubled mind to a true friend,
and it seems to make the heart lighter to have words of consolation given in
the hour of trial from a true, loving friend. Many a young person and many
aged ones can bring back to memory the same solemn fact.
Thus it was with Nettie as she went homeward. Warren’s kind words ever rang
in her ears: “He is a man of honor; if he told my little cousin he loved her it is
the truth.”
How many times in the future did she think of them and draw consolation
from them.
Warren watched the stage that bore his cousin homeward until it was out of
sight, then started homeward at a brisk pace.
He had not gone but a few miles when he overtook Paul returning from
hunting. On his shoulder hung several pheasants.
Warren brought his horses to a halt as he said, “Take a seat by my side, Paul, it
is better to ride than to walk. Are you not tired? You must have gone out early
this morning, as I heard the report of your gun when I went to town.”
“Yes,” answered his companion getting into the buggy, “I came out very early,
as mother is not as well as usual and I thought some wild food would be good
for her. I fear my mother is not long for this world, as she is failing every day. I
sent Pompey for the doctor this morning, but mother says it will do no good,
as she is past cure. Oh, Warren, I do not know what to do or where to turn,
for I am in deep trouble. Why don’t you come over oftener and stay some
night with us?”
“Would your mother be willing? She is so delicate about company,” answered
Warren.
“She would be very happy indeed to see me have company,” said Paul.
“I will come over in a day or so,” said Warren.
“Please do, Warren, in an hour of need, as I am very lonely—mother sick, and
she is my only companion except the servants.”
They came to a cross road that was nearer for Paul to reach home and he
sprang lightly out and ran swiftly home with his game.
Nettie’s homeward journey came to an end in due season, nothing happening
of any account worth mentioning. As she came sooner than her mother
expected her she was surprised to see her child back again.
In less than a week after greetings were exchanged and many questions asked
about distant friends the mother said, “Why, Nettie my child, why did you not
stay longer? I did not expect you for two weeks at least.”
CHAPTER V.
“Oh, mother, I could not stay away any longer from you. It seemed a long
time to me.”
“Why, my child, in your letter you said you was happy and would stay two
weeks, as your uncle and cousins would not take ‘no’ for an answer and wished
we should come and live with them; and I was nearly making up my mind to
go up there for a while and see the country. Perhaps it would be agreeable to
my health.”
The mother was viewing her child critically while speaking. Noticing Nettie’s
face changing from a bright crimson hue to a pale color, and not answering
her, she said, “Has my little girl quarreled with anyone out there and come
home angry?”
“No, no mother,” answered Nettie.
“It is worse than that, mother; I will tell you all, as no true mother would
advise her child to do wrong. I will tell you all, but do not think for one
moment I was telling you an untruth when I told you I could not stay longer. I
could not under the circumstances, and it seemed a long time to leave you here
alone. Well, mama, now for my story: My cousins made a party for me last
Friday evening, as you know Friday was my birthday, and invited all the young
people in that vicinity, and among them was a rich young man, highly
esteemed for his true manliness. Cousin Warren says he has known him ever
since he can remember, as they have grown up and trudged to school together,
and says he never caught him in a lie. That is saying a good deal about him.
Well, the Monday before the party cousin went to town and I went down to a
beautiful lake on uncle’s farm to gather flowers. I sat down on the brink of the
lake and some of the flowers fell into the water. I was wondering how to get
them when the same young man spoken of came and fished them out. He
gave me his card, and the night of the party he told me the same old, old
story.”
“What did you tell him Nettie?”
“Oh, nothing in particular. The most I told him at last was if he proved true to
me in the future I was his.”
“Nettie, dear, do you really love him?”
“Yes mother, with my whole heart. But I have run away and if he really loves
me he will hunt me up,” said Nettie, her face beaming with smiles.
“Nettie,” said her mother, “pray what is the name of your admirer?”
“Paul Burton, of Pine Island. The name was given to the farm many years ago.
It is a beautiful farm enclosed by the forest, and there is a little lake on it; and
in the center pine trees are growing. I was out with cousin and he took me by
there.”
Nettie was speaking with enthusiasm and hearing her mother repeating the
name she turned and noticing her mother’s pale face said, “Mother, what ails
you? Are you sick?”
“No, Nettie, the name sounds familiar. What kind of a looking man is this Paul
Burton, and what is his age?” asked the mother.
“He is tall—about six feet—well proportioned, his eyes are dark blue, and he
has auburn hair, and is a picture to behold,” answered Nettie.
“Blue eyes and auburn hair; did his hair curl?” asked her mother.
“Yes,” answered Nettie, “and he is about twenty-two or three. He lives alone
with his mother, who is a frail, sickly woman.”
“Did you ever see her?”
“No, mother, but cousin says she is tall and dark complexioned, with black
eyes, and her given name is Margaret or Margretia, I do not know which.”
“It is the same woman and must be their son. Oh, my God! why have I come
to this?” exclaimed Mrs. Spaulding.
“Why, mother, what is the matter, and who are you referring to?” asked Nettie,
noticing her mother’s pale face.
“My child, one you never saw—and I hope you may never meet him or any of
his descendants.”
“Why, mother. His descendants should not be cruelly judged by his conduct.
You speak as though he had been guilty of some great criminal act. I do not
see what he has to do with Paul Burton, the young man I was speaking of,”
said Nettie, turning and looking out of the window.
“If I had known it would have troubled you, mother, I would not have told
you anything about him. You seemed so anxious to know why I returned so
soon I thought it proper to tell you all. The young man was supposed rich and
I was a poor girl with only my good name to sustain. I deemed it best to try
his love. If he loves me sincerely he will find me; if he does not, it is better I
should be far away. Do you not think my act justifiable, mother?”
“Yes, my child, you did what is right and proper, and I am glad you came
home, and I hope my conjecture is not true,” answered the mother
sorrowfully.
Nettie went to her mother and pressed a kiss on her pure fair brow. She had
passed through many severe trials, yet she remained beautiful—only a trifle
pale. Time made little impression upon the fair form of the once beautiful
Minnie Hilton, one of old England’s fair daughters.
“Nettie, I have a long story to tell you. It might prove a good lesson to you in
the future, as you are young and inexperienced in this world of sunshine and
shadow, and you may draw conclusion from the story.
“My child. I hope you will not have to endure the troubles and sorrows like
the lady of whom I am going to speak.”
“Oh! mama, do tell me now, as I am anxious to hear it. I am sure it is a
warning to me,” said Nettie, tapping the velvety cheek of her mother.
“Well, Nettie, many years ago in England there once stood a neat cottage
surrounded by a group of beautiful trees, and just within hearing of the big
bell in London. What a happy little home it was before the revolution broke
out in this country. England was all confusion, especially among the second
and lower classes of people. The inmates of that little cottage numbered four
—father, mother, a lovely girl of eighteen summers, and a lad of sixteen, as
honest a boy as ever lived and a kinder heart never beat today. Well, the father
had to help to fill the ranks of England’s army and came over here to fight for
King George. How noble and manly he looked in his red coat as he mounted
his coal black steed. He made a fearless and brave soldier, as many of his
comrades testified on their return home. But he who kissed his wife and
children an affectionate farewell never returned to receive their welcome
embrace of joy as did many of his fellow soldiers. As the news spread quickly
over the old domain that the battle of Bunker Hill had been fought many tears
fell for the fallen soldiers who fell in that sad fray.
“Sad was the news indeed, to hear that the father of this happy household was
no more, during the intervening term of his going away and time of his death.
The daughter of this family was the fairest in England at that time. Her fame
for beauty rang far and near. One day in summer when the commons were
robed in green, besprinkled with buttercups and daisies, this young lady for a
little pleasure rambled over the green, picking the flowers and thinking of her
father who then was far away in the battle fighting for his king, when close to
her she espied a large stray sheep of the masculine gender. He had probably
broken out from its owner’s enclosure and was wandering over the commons.
As soon as he espied the lady he came toward her with his head bent to the
ground, and the lady gave a scream and was running toward the hedge fence
of thorns; and just as the sheep was about to strike her a young man rode
rapidly between them, striking the sheep with a heavy loaded whip, which
felled him to the ground as though dead. The gentleman sprang lightly from
his horse and picked up the inanimate form of the lady, as if she was an infant,
and bore her to a cottage near by, and by the aid of spirits she soon returned
to consciousness. She had swooned with fright and had fallen, hitting her head
lightly on a rock, cutting a cruel wound which bled profusely. The young man
saw the blood and he only had thought for the fair young form as he quickly
bore it to a friendly shelter, letting his horse roam at will. The lady was too
weak to walk, so the gentleman went home and took his father’s carriage and
took her home; as he called every day for several days to see how his patient
was getting along he grew deeply in favor with the little family of the cottage.
The young lady looked for his coming and was deeply grieved when she
learned who he was, for he was the son of a baronet, a gentleman of note
among the upper classes of people. He was a lovely young man, and one
beloved by old and young throughout the community. He called often at the
cottage. None of the inmates could tell him to come no more, as he was both
manly and honest, and with each day he grew more enamored with the little
lady he had saved from a cruel death. How time flew away! Soon his father,
who was not noted for kindness, began to notice his son’s movements, and it
soon became known to him where he wandered. As his son was of age he had
him sent off to the war, as he would then get over his love passion for the little
cottager, as he called the little lady his son admired. Sad was the last meeting of
the young couple, as he came to bid her farewell. Many were the promises
given each to prove faithful until death. Then another blow was given that
household, as he in his red coat rode away leaving his promised bride to
mourn the loss of one she deeply loved. Soon after came the news of the
battle of Bunker Hill, and the father of this little cottage was no more. Deeply
mourned the inmates for the friend and father, and also for the absence of one
who seemed a true friend to all; but he was the King’s subject and had to go
and leave a lover behind him to mourn his absence, as many over our land
today have done, and how sorrowful the earth seems to the ones left behind.
“The young man went away in hopes of a speedy return, but what a sad
delusion! One year passed, then a second, and a letter came to the loved one
far over the deep that her lover was slain. How deeply that little girl mourned
for her supposed dead lover no human tongue can tell, and as time flew away
many were the changes with the inmates of that cottage. Finally in time the
mother concluded to remove her family over here to America. She wished to
view the resting place of her beloved companion, and when the shadows of
death came to her weary soul her form might lie in the same soil, beside her
husband. Cold and stormy was the day when the noble ship set sail that bore
on its bosom the widow and her children. It was the following autumn when
they landed in New York, six weeks after setting sail. The widow rented a little
cottage and made the place her future home. Her children both had grown to
manhood and womanhood, and having a good education managed to maintain
themselves respectably.”
“Oh, mama, you did not tell me whether the young lady ever heard definitely
about her lover’s death,” said Nettie, breaking in on her mother’s narrative.
“My child,” answered her mother, “she left word with some of her friends that
if any news came to them concerning him they should write to her
immediately. She received only one letter bearing news of him. It said he had
returned before the widow had left England. It was reported by the young
man’s proud family that he was dead, for they knew their son’s disposition
would be to fulfill his promise to the ‘little cottager,’ as they called his
promised bride. They were bound it never should be. At the last meeting
before he went to war he frankly told his father he should marry the girl on his
return home; he might disinherit him if he chose—he would have a few
shillings of his own and he would take his wife over to the new land he was
going to fight on. This exasperated the father to such an extent that he
brought his fist down on the table and swore an oath it never should be. The
son did seem not to heed his father’s words, as he was sure the lady would
prove faithful and he would soon return and claim her, in spite of all earthly
beings. The lady watched and waited until nearly autumn for a letter from her
loved one which never came. During that time she received news of her lover’s
death, then broken hearted, she urged her mother to leave the place which,
with each day, brought memories of the two loved ones who never would
tread o’er its well-remembered threshold. The young lady lived single eight
years. She employed the time in teaching primary school in the suburbs of the
city of New York. Time, the great healer, brought consolation to the wounded
heart. At last she accepted the hand of a young merchant. The old love was
buried beneath the new, but never forgotten. The young lady’s brother learned
the trade of a mechanic but did not like it very well, and like Washington
turned to agriculture as soon as he earned money enough to buy a farm. The
widow often went to view the grave of her beloved companion, and when her
life on earth was ended her children laid her silent form beside him she loved.”
“Why, mamma!” exclaimed Nettie, the tears trinkling down her fair cheeks, “it
was my own grandmamma, as I can just remember when papa and Uncle John
took her deceased form away and did not get back for a long time,” said
Nettie, speaking slowly.
“Why, mamma, can the young lady you have been speaking about be
yourself ?”
“Yes, my daughter, it is the same.”
Nettie was standing by her mother’s chair, stroking the fair brow of her only
parent, deeply thinking over all she had been told.
Soon she said, “Mamma, it was very sad indeed, but I do not see why it should
be a warning to me.”
CHAPTER VI.
“My child,” answered the mother sorrowfully, “you will be surprised when I
state that the young man did go home and did not try to find where we
removed to, but soon became acquainted with a lady of high standing and
married her. They came over here, bought a large tract of land somewhere in
the New England states. Your father and I met him once on board a vessel
lying in harbor. Your papa, dear soul, knew of my first love and also the name
of his predecessor, and getting an introduction to him made himself very
inquisitive, as he found he was the same person and had been married some
twelve years. You see how deceitful some people are in this world. It is a good
saying and a true one, too, that ‘sometimes you think a friend you’ve got until
trial proves you have him not.’ Thus it proved out to be to me.”
“Mamma,” answered Nettie, “I am a trusting spirit. It might not have been all
his fault. He might have been deceived, as the story circulated by the family
deceived you. Perhaps he did try to find you but could not get any clue to your
whereabouts, as money sometimes will do a great deal in the way of bribing
people.”
“Well. Nettie, time will prove all things. As it is said, ‘Right conquers might.’”
“Mamma, what is the name of the once young man you have been speaking
of ?”
The mother looked sadly up in her daughter’s fair face as she answered, “Paul
Burton; with manly form, blue eyes, and hair the color of your admirer’s.
Nettie, I am so glad you had sense enough to come home, as it is my
conjecture that this young man is the son of him I have told you of. God grant
it may not be!” said the mother fervently. “I do not wish my child to be
deceived as I have been.”
“Your father and I lived very happy through the years of our married life. No
shadows came to mar the horizon of our union until he became bankrupt
through a person we supposed our friend. Poor soul, like many others before
him he could not stand the crash in his financial affairs, and soon after died. It
was a sad blow to me as I loved him fully as well as I ever did Paul Burton, the
baronet’s son.”
“Poor mamma!” exclaimed Nettie passionately. “God must have willed it to be
so. I love this strange young man and it was very hard for me to come home
and leave him whom I loved so fondly, but my English pride bade me come
home.”
“And I hope God will deal justly by us all. We must trust to Providence and
wait and see what time will bring in the future.”
“Oh mamma dear, I cannot believe Paul is false. Oh, no, no, it cannot be!”
exclaimed Nettie passionately.
“May God be merciful to me.”
“My child. God doeth all things. We can trust to Providence and all yet may be
well. This is a world of trouble and sorrow to us poor mortals and what falls
to our lot we must endure patiently, for what is to be will be, in spite of all
human aid. I sincerely hope for the happiness of my only child,” said the
mother, pressing Nettie fondly to her breast.
Here I will leave them bemoaning their fate, and return to Paul, who, on
returning home, found his mother very ill. She gradually grew worse day by
day. All medical skill was of no avail and they could not restore her to ordinary
health. Time passed drearily at that once pleasant home. Paul, sad hearted,
went about the house as one in a dream, never speaking to any one except to
give orders to servants and inquire about his mother, whom he loved more
fondly than ever. He knew she would soon leave him, and it grieved him very
much to see her sad, pale face as she would look fondly at him and say, “I will
soon be at rest—free from all earthly trouble.”
She lingered through the fall and long dreary winter months, and as the buds
came on the trees in the following spring she breathed her last, while lying in
the arms of her affectionate son. Sad was the scene, to see the young man
fondly clasp his mother to his breast while tears fell like rain, on the sad, silent
face.
A few moments before she died she called for her son, and when he did not
come immediately she said, “Must I die and not tell him? I ought to have done
it before now. Oh, where is my boy? Will he come soon?” she asked faintly,
turning her face to the wall.
Pompey, hearing her call, went into the room in time to hear her last words.
He went to her bedside as he said, “Paul will come soon. He went down the
lane to see if the doctor is coming. I’s sent for him and he will come very fast
when he hears de news. Missus, I’s been berry kind and obedient to you, ain’t
I? I’s lived with you ever since Paul was a little chick. Anything you want me to
tell him, Missus?”
“Yes, my faithful man, you know the whole history of my life, and when I am
gone tell him not to censure his father as it was all my fault—his leaving home;
but make my sin as light as you can. There is a little tin box in the garret that
will tell him all he wishes to know.”
She nearly held out her hand to the faithful man, saying, “It’s very hard
bidding you goodbye, Pompey, and may God bless you forever!”
She whispered the last words, and as her son came into the room her eyes
brightened for a moment and she tried to speak to him but could not. Her
breath grew shorter and shorter with each moment, and soon she was no
more.
They laid her beneath the weeping willow tree and at her grave the son placed
a neat monument in memory of her who reared him to manhood. Sad and
dreary was that house to Paul. The sunshine had fled and only shadows
remained. No mother now to kiss him good night; no father to bear with him
this sorrow, and the only being he loved beside his mother was gone, he knew
not where. The only friends that deeply sympathized with him except the
servants were John Hilton’s family, especially Warren, who was there night and
day and kept Paul company through this sad affliction. When this kind
companion went home Paul could not reconcile himself to stay in the house
where once was life and joy for him.
“I cannot stay here; I must go somewhere; there is no comfort for me on this
earth. Oh, why did I live to see this trouble!”
Thus he would talk to Warren Hilton when they were alone.
“Why do you not go away from here for a while? The servants can look after
the farm, and I will run over now and then to see how they get along. You can
write me and you can hear all about them. You can go down to the city of
New York, or anywhere else you choose. Something may change for the best. I

Atlas of Sexually Transmitted Diseases: Clinical Aspects and Differential Diagnosis 1st Edition Mauro Romero Leal Passos (Eds.)

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Atlas of Sexually Transmitted Diseases:

Clinical Aspects and Differential

Sexually Transmitted Diseases Sourcebook 7th Edition

Differential Diagnosis of Common Complaints Robert H.

The Heart in Rheumatic Autoimmune and Inflammatory

Pythium Diagnosis Diseases and Management 1st Edition

Pictorial Atlas of Soilborne Fungal Plant Pathogens and

Atlas of Inherited Metabolic Diseases 4th Edition

Atlas of Diffuse Lung Diseases A Multidisciplinary

Clinical Diagnosis and Management of Gynecologic

Clinical Aspects and

Atlas of Sexually Transmitted

ISBN 978-3-319-57468-4 ISBN 978-3-319-57470-7 (eBook)

Library of Congress Control Number: 2017953048

© Springer International Publishing AG 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

What a Professional Involved in STD Should Know

–– Annual new infections (incidence), 20 million dollars, USA, 2008.

Therefore, It Should Not Be Postponed

Major Syndromes to Be Observed in STD/Genital Infections

–– Genital ulcers (genital herpes, syphilis).

People with immunodeficiency (AIDS, malignant neoplasm, use of immunosuppressant) can

Sensitivity of a Laboratory Test

–– Measures the test ability to detect an infection.

Specificity of a Laboratory Test

–– A prejudiced attitude towards gender/sexuality, skin color, education, socioeconomic and

Niterói, Rio de Janeiro, Brazil Mauro Romero Leal Passos

1 The Skin and Eruptives Lesions ������������������������������������������������������������������������������� 1

Gutemberg Leão de Almeida Filho, M.D., Ph.D. Institute of Gynecology, Federal

Humberto Abrão Humberto Abrão Laboratory, Belo Horizonte, MG, Brazil

M. Ferrer Gispert, M.D., Ph.D. Department of Obstetrics and Gynecology, Dexeus

José Carlos Saddy Saddy Diagnóstico, Niterói, RJ, Brazil

1.1 Introduction 1.2 Skin Structure and Function (Fig. 1.1)

© Springer International Publishing AG 2018 1

Fig. 1.1 Skin Structure

Hair follicle Artery

Fig. 1.2 Epidermis Corneal Extract

Fig. 1.3 Epidermal

Occludens zone Slot joint Desmosome

Fig. 1.4 Dermoepidermal

1.2.2 Dermis 1.3 Dematological Diagnosis

1.3.1 Dermatologic Semiology • Cyanosis: purple, reduced hemoglobin, conse-

Fig. 1.5 Eruptive lesion with color change—erythematous spots

Solid Lesions (e) Gumma

Fig. 1.8 Eruptive lesion, solid lesions, vegetation/condylomatous

Fig. 1.7 Solid eruptive lesion, nodule (cystic inclusion)

Liquid Content Lesions

(a) Vesicles (Fig. 1.10)

Fig. 1.9 Eruptive lesion, solid lesions, verrucous aspect(condyloma

Fig. 1.10 Eruptive lesion of liquid content, vesicles (genital herpes)

Lesions with Cutaneous Thickness Change

Fig. 1.12 Eruptive lesion of liquid content, abscess (lymphogranuloma

Fig. 1.13 Eruptive lesion with changes in cutaneous thickness, infiltra-

Fig. 1.14 Eruptive lesion with changes in cutaneous thickness, atro-

Lesions with Continuity Solutions

Senile Lesions (c) Eschar

Fig. 1.19 Eruptive lesion,

1.3.1.2 Shape and Disposition of the Lesions Lesions Distribution

2.1 Synonymy • 21–30 days: Hard or inoculation chancre—a single lesion

2.4 Etiologic Agent

Treponema pallidum, subspecies pallidum. This is a Gram-­ 2.5.2 Latent Syphilis

2.5 Clinical Presentation

What a Professional Involved in STD Should Know

Therefore, It Should Not Be Postponed

Major Syndromes to Be Observed in STD/Genital Infections

Sensitivity of a Laboratory Test

Specificity of a Laboratory Test

Niterói, Rio de Janeiro, Brazil Mauro Romero Leal Passos

1 The Skin and Eruptives Lesions �� 1

1.1 Introduction 1.2 Skin Structure and Function (Fig. 1.1)

1.2.2 Dermis 1.3 Dematological Diagnosis

1.3.1 Dermatologic Semiology • Cyanosis: purple, reduced hemoglobin, conse-

1.3.1.2 Shape and Disposition of the Lesions Lesions Distribution

2.1 Synonymy • 21–30 days: Hard or inoculation chancre—a single lesion

2.4 Etiologic Agent

Treponema pallidum, subspecies pallidum. This is a Gram- 2.5.2 Latent Syphilis

2.5 Clinical Presentation