The Great Imitator

A 25-year-old man presents to urgent care with a two-week history of a diffuse rash. It started as faint pink macules on his chest and back, then spread to his arms and legs, and he now notices discrete papules on his palms and the soles of his feet. He reports mild fatigue, low-grade fever, and notices that the lymph nodes in his groin and neck are tender and enlarged. He is otherwise healthy and takes no medications.

On further questioning, he recalls a painless sore on the shaft of his penis approximately six weeks ago. It lasted about two weeks and resolved on its own; he attributed it to a friction injury and did not seek care. He is sexually active with multiple male partners and reports inconsistent condom use. His last HIV test three months ago was negative.

On examination, temperature is 38.1°C. There is a generalized maculopapular rash involving the trunk, extremities, and notably the palms and soles. No mucosal lesions are seen. Bilateral inguinal and cervical lymphadenopathy is present. The remainder of the examination is unremarkable.

The palmar rash is shown below.