Snail-track Ulcer of Greatest Mimicker

A 34-year-old male presented to the emergency department with a 1-week history of a raw lesion over the glans penis. Physical examination revealed an ill-defined, serpiginous, shallow ulcer on the glans, with a slough-covered base [Figure 1a] along with significant lymphadenopathy in the cervical, axillary and inguinal regions. The patient reported a history of unprotected sexual intercourse with multiple partners. Serological testing demonstrated a rapid plasma reagin (RPR) titre of 1:128 [Figure 1b], and the Treponema pallidum haemagglutination assay was positive. Fourth-generation enzyme-linked immunosorbent assay testing for human immunodeficiency virus antibodies was negative. The diagnosis of secondary syphilis of unknown duration was established. As per Centres for Disease Control and Prevention guideline, he was treated with weekly dosage of intramuscular benzathine penicillin G 2.4 million units for 3 weeks. The ulcer resolved within 2 weeks. A follow-up RPR performed 3 months later showed a titre reduction to 1:16, consistent with an appropriate serological response to treatment.

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Figure 1:

(a) Ill-defined, serpiginous, shallow ulcer on the glans, with a slough-covered base, (b) Rapid plasma reagin titre 1:128 of same patient.

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