Biett’s sign: a hallmark sign of secondary syphilis

A previously healthy 39-year-old man presented with a 2-week history of a painless diffuse erythematous rash (Figure 1). He had had multiple sexual partners and unprotected intercourse. Physical examination showed diffuse lymphadenopathy and multiple erythematous macules (diameter, 1-2 cm) with an off-white scaly peripheral collarette (Biett’s sign) (Figure 2), which are typical findings of syphilitic roseola. Screening for sexually transmitted infections revealed positive results on Venereal Disease Research Laboratory (titer 1:256) and Treponema pallidum hemagglutination tests; serologically, he tested negative for human immunodeficiency virus, hepatitis B, and hepatitis C. He received a total of 4.8 million units of penicillin G benzathine over two weeks. At the 1-month follow-up, cutaneous lesions were absent; he was asymptomatic.

FIGURE 1:
Diffuse erythematous macules with collarette scales.

FIGURE 2:
Syphilitic roseolas with Biett’s sign.

Syphilis is a sexually transmitted infection that is re-emerging with increasing prevalence worldwide^1,2. Secondary syphilis shows two typical types of rash: one occurring early in this phase called syphilitic roseolas, characterized by light pink to erythematous macules, and one occurring later in this phase named syphilids, marked by erythematous papules^2,3. Both have hallmark collarette scales, known as Biett’s sign. Additionally, cutaneous manifestations may demonstrate atypical morphology, such as nodulo-ulcerative, annular, and pustular lesions, among others^1,3. Due to varied clinical presentations, secondary syphilis is recognized as “the great imitator” and must be considered as a differential diagnosis of all dermatoses with atypical presentation. All secondary syphilis cutaneous lesions contain highly contagious spirochetes; its non-recognition and late treatment favor an increased risk of disease transmission.

REFERENCES

• ¹ Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006;81(2):111-26.
• ² Peeling RW, Mabey D, Kamb ML, Chen XS, Radolf JD, Benzaken AS. Syphilis. Nat Rev Dis Primers. 2017;3:17073.
• ³ Hook EW Rd. Syphilis . Lancet. 2017;389(10078):1550-57.

Publication Dates

• Publication in this collection
  11 Apr 2019
• Date of issue
  2019

History

• Received
  06 Nov 2018
• Accepted
  17 Dec 2018