A Rare Presentation of Late Latent Syphilis With Alopecia and Polyarticular Joint Pain in a 17-Year-old Teenager

To the Editors: Sexually transmitted infections (STIs) remain a significant public health threat worldwide, with approximately 5 million new cases reported annually.1 In the US, syphilis rates have surged to their highest levels in nearly 75 years, with alarming statistics reported by the Centers for Disease Control and Prevention (CDC) in 2022.2 In this report, a 17-year-old male was referred to the infectious diseases clinic with a 3-month history of polyarthritis, hair loss, and fatigue. His physical exam was remarkable for a diffuse, faint macular rash on his torso without involvement of the palms and soles, patchy hair loss with thinning with several well-circumscribed patches of baldness predominantly located at the crown, temples bilaterally and nape (Fig. 1); bilateral cervical lymphadenopathy; and swelling in both ankles and elbows (epitrochlear region), accompanied by tenderness but no erythema.FIGURE 1.: Head exam demonstrating patches of alopecia.Initial workup showed normal labs with negative antinuclear antibody, rheumatoid factor, and HLA-B27. However, inflammatory markers, ESR and CRP, were elevated. Radiographs of the upper extremities demonstrated bilateral elbow joint effusions with soft tissue swelling overlying the dorsum of the wrists bilaterally. Juvenile rheumatoid arthritis was considered and he began treatment with Naproxen sodium, achieving only partial relief. He reported being sexually active with multiple male partners. STI testing results revealed positive syphilis antibodies and a reactive RPR titer of 1:256, leading to a diagnosis of late latent syphilis. Due to uncertainty regarding the time of onset, he was treated with IM benzathine penicillin G 2.4 million once weekly for three doses. Upon follow-up visit, he reported thickening and growth of his hair as well as complete resolution of his arthralgia. On examination, there was no evidence of cervical lymphadenopathy, and the musculoskeletal exam was unremarkable. Repeat RPR titers posttreatment were 1:64, suggesting an adequate therapeutic response. This case underscores the rare and/or less commonly reported clinical presentations of syphilis involving multiple organ systems. The CDC recommends STI screening, including HIV, particularly in individuals at risk such as young men who have sex with men (MSM) of color.2 Black MSM are disproportionately affected by STI, they represent 1% of the US population; however, 20%–30% are diagnosed with HIV every year.3 These racial disparities are more related to access to sexual health care rather than sexual behaviors.2,3 In addition, pre-exposure prophylaxis with emtricitabine (FTC) plus tenofovir disoproxil fumarate or tenofovir alafenamide is recommended for HIV prevention, with the former regimen initiated for our patient.4 Doxycycline for postexposure prophylaxis is a newer tool aimed at preventing STIs, including syphilis, gonorrhea, and chlamydia, particularly for MSM and transgender women.