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Revista da Sociedade Brasileira de Medicina Tropical

versão impressa ISSN 0037-8682versão On-line ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.52  Uberaba  2019  Epub 11-Abr-2019 

Images in Infectious Diseases

Biett’s sign: a hallmark sign of secondary syphilis

Fred Bernardes Filho1

Ana Laura Rosifini Alves Rezende1 

Marcos Davi Gomes de Sousa2 

1Divisão de Dermatologia, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.

2Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil.

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 worldwide1,2. 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 papules2,3. 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 others1,3. 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.


1. Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006;81(2):111-26. [ Links ]

2. Peeling RW, Mabey D, Kamb ML, Chen XS, Radolf JD, Benzaken AS. Syphilis. Nat Rev Dis Primers. 2017;3:17073. [ Links ]

3. Hook EW Rd. Syphilis . Lancet. 2017;389(10078):1550-57. [ Links ]

Recebido: 06 de Novembro de 2018; Aceito: 17 de Dezembro de 2018

Corresponding author: Dr. Fred Bernardes Filho.

Conflict of interest: The authors declare that there is no conflict of interest.

Creative Commons License This is an open-access article distributed under the terms of the Creative Commons Attribution License