I feel like everyone who writes Erik as having started out looking like everybody else and then gotten acid thrown at him or whatever is forgetting the legit, actual thing that existed in the 19th century (and earlier, and now) that could eat someone’s nose off and had a huge social stigma attached


Why do we not have a phic where Erik was a handsome young man who fell in love with someone and contracted syphilis and lost his nose because of that?

I’m ready for a syphilitic!Erik phic

Patient referred to derm from primary care last week for “likely dermatophyte infection” “treated with oral itraconazole and referred to dermatology.”

Right off the bat, I have a few problems with this.

1) Oral antifungals are NOT the first line treatment for a dermatophyte infection (unless it involves the hair or nails). It will work, but it’s a big gun.

2) Why did you refer to derm without following up if you thought you treated the infection? That’s an inappropriate use of specialty care - if it was indeed a dermatophyte infection, the rash should clear, no need to send to derm.

3) Physical exam reported “Skin: maculopapular rash”. That’s it. Where was this rash? How extensive? Did you actually look at it?

So we were expecting to see a patient with either a completely resolved dermatophyte infection or something that is not at all fungal. 

Patient comes in with a generalized, nonpruritic, non-tender rash consisting of scaly papules. Rash involves palms, soles, and genitalia.   

If this was a Step question, what do you think the answer would be?
  • a) dermatophyte infection
  • b) secondary syphilis
  • c) rocky mountain spotted fever
  • d) psoriasis

It’s syphilis. It’s a frickin’ beautifully classic presentation of secondary syphilis. What do we learn in med school is a rash that involves the palms and soles? Syphilis. Who should be able to recognize and treat syphilis appropriately without referring to derm? Primary care.

The resident and I walk out of the room, look at each other and simultaneously say, “Syphilis.”

RPR and PCR both came back positive (though HIV, G&C were all negative, which is good news) and the patient got his penicillin. 

The reason this really bothers me though is that it felt lazy on the part of the PCP, and as a future PCP it makes ME look bad when people in my profession are lazy. AND, that poor patient had to walk around with syphilis rash all over his body for a few weeks while waiting for a derm appointment to become available - they didn’t exactly rush him in for his “likely dermatophyte infection.” GRRRR.

Tertiary syphilis is a disturbing thing to see. The disease can result in death, causing damage to the brain, heart, liver, bones, joints, eyes, the nervous system and blood vessels. Before it kills you, it can result in blindness, paralysis, dementia and loss of motor control. The individuals in the above picture were alive when these pictures were taken.

A boy suffering from congenital syphilis. The suffering this illness caused in pre-penicillin eras was completely excruciating. Approximately 15 percent of the entire population of Paris was believed to carry the disease by the end of the 19th century. Syphilis was shameful in these times, as many men got it from prostitutes working at brothels and whorehouses - symbols of decadence and debauchery in the public eyes - where it roamed free and untamed. Many people suffered in silence for whole lifetimes, subjecting themselves to treatments as horrible, prolonged and dehumanizing as the sickness itself.

See, syphilis does not necessarily kill you right away; many lived with their horrible syphilitic terror for 40 years or more. A most sinister, detailed account for it in can be found in the diary later published as La doulou: extraits du journal d'Edmond de Goncourt, describing french writers Alphonse Daudet’s gruesome ordeal in late 1800’s France.