A 28-year-old man presents with a painless ulcer on the glans penis for 3 weeks. Examination reveals a solitary, indurated lesion with a clean base and raised borders. Dark-field microscopy of exudate is positive. All of the following are features of primary syphilis EXCEPT:

Question

Accepted Answer

A. Regional lymphadenopathy (bubo) is suppurative and drains pus. ## Understanding Primary Syphilis Features

**Key Point:** Primary syphilis presents with a chancre — a painless, indurated ulcer with a clean base and raised borders. The key distinguishing feature of syphilitic lymphadenopathy is that it is **non-suppurative**.

### Correct Features of Primary Syphilis

| Feature | Characteristic |
|---------|----------------|
| **Chancre appearance** | Painless, indurated, clean base, raised borders |
| **Regional lymphadenopathy** | Non-suppurative, firm, mobile, rubbery (bubo) |
| **Healing** | Spontaneous healing in 3–6 weeks without treatment |
| **Diagnosis** | Dark-field microscopy, DFA, or RPR/VDRL serology |

**High-Yield:** The **non-suppurative nature** of syphilitic lymphadenopathy is a cardinal distinguishing feature. In contrast, lymphogranuloma venereum (LGV) and haemophilus ducreyi (chancroid) produce **suppurative, draining buboes**.

### Why Option 1 (Suppurative Bubo) is Wrong

Syphilitic regional lymphadenopathy is characteristically **firm, rubbery, mobile, and non-suppurative**. It does NOT drain pus. A suppurative, draining bubo is typical of:
- **Lymphogranuloma venereum** (Chlamydia trachomatis L1–L3)
- **Chancroid** (Haemophilus ducreyi)
- **Donovanosis** (Klebsiella granulomatis)

**Clinical Pearl:** The non-suppurative bubo of syphilis may persist for months even after the chancre heals, making it a useful diagnostic clue in the secondary stage.

### Differential Diagnosis of Genital Ulcers

| Organism | Ulcer Character | Lymph Node | Suppurative? |
|----------|-----------------|-----------|---------------|
| *Treponema pallidum* | Painless, indurated, clean base | Bubo (firm, mobile) | **No** |
| *Chlamydia trachomatis* (LGV) | Painful, shallow | Bubo (firm, mobile) | **Yes** |
| *Haemophilus ducreyi* | Painful, purulent | Bubo (firm) | **Yes** |
| *Klebsiella granulomatis* | Beefy red, painless | Rarely enlarged | Variable |

[cite:Park 26e Ch 8]

Answer

B. Lesion heals spontaneously within 3–6 weeks even without treatment

Answer

C. Dark-field microscopy or direct fluorescent antibody test confirms diagnosis

Answer

D. Chancre is typically painless and indurated

A 28-year-old man presents with a painless ulcer on the glans penis for 3 weeks. Examination reveals a solitary, indurated lesion with a clean base and raised borders. Dark-field microscopy of exudate is positive. All of the following are features of primary syphilis EXCEPT:

Explanation

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