Primary anal syphilis can manifest as a painless fissure. If left untreated it can progress to secondary syphilis manifested in the perianal area as condyloma latum, multiple raised warty lesions that coalesce. Tertiary syphilis can occur at more than 1 year following primary infection, manifesting as neurologic, cardiovascular, renal, hepatic, mucosal, and ocular symptoms. Once the diagnosis is considered, a biopsy is performed on the suspicious ulcer and the tissue is evaluated under darkfield microscopy and with serologic testing. Therapy consists of a 2.4 million units intramuscular benzathine penicillin injection. In patients allergic to penicillin, doxycycline may be used.
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