Laboratory Data

Microscopic examination reveals scale crust, irregular ("saw-toothed") epidermal hyperplasia with hypogranulosis, exocytosis of neutrophils, interface change and a moderate to dense lichenoid lymphohistiocytic infiltrate with numerous plasma cells. While the epidermal change (neutrophil-rich scale reminiscent of Munro microabscesses and hypogranulosis) raises the possibility of psoriasis, the lichenoid inflammatory infiltrate and abundance of plasma cells is somewhat unusual for psoriases and broadens the differential diagnosis to include secondary syphilis. The latter diagnosis is favored based on the presence of rare slender organisms in the papillary dermis (very closely abutting the epidermis) with Warthin-Starry stain and positive serology.

Probably secondary syphilis; ?? early tertiary.

He received 2.4 million units of benzathine penicillin G on three occasions one week apart.

This patient alerts us to the fact that old diseases are waiting to reappear. Syphilis is the great imitator and its manifestations are protean. One wonders if his HIV and immunosuppresion may have modified the appearance of his skin lesions of syphilis. Interestingly, he reported no Herxheimer reaction after the first injection. Most of us see only an occasional case of syphilis and are not experts any longer. Even in my small practice, I saw another patient with syphilis recently. This was another man who had passive anal sex with a stranger and developed rectal warts a few weeks after. His VDRL was positive. Initial HIV titer negative, but he still needs to be retested for a few months.

After a marked decline in the number of syphilis cases in the context of AIDS prevention campaigns, a significant increase has been observed in states of the former Soviet Union since 1994. In recent years, outbreaks have also been reported in the US, Canada, and several European countries. The current epidemic in the US and in different parts of Europe has largely involved men who have sex with men, many of whom are infected with HIV. Since a misdiagnosis of syphilis can have serious consequences for the patient and also for pregnancies and newborns, clinicians should be aware of the many manifestations of syphilis and difficulties in the diagnosis and management of the disease. Younger clinicians in particular are no longer familiar with the diverse clinical symptoms and the complex diagnostics of syphilis. Patients co-infected with HIV may present with atypical clinical manifestations and laboratory test results. Furthermore, through its association with an increased risk of HIV infection, syphilis has acquired a new potential for morbidity and mortality, and the diagnosis of syphilis should be routinely considered in patients with uveitis, sudden deafness, aortic thoracic aneurysm, or pregnancy. Only a minority of syphilis infections are detected in the primary stage. This may be because of atypical locations and, occasionally, atypical morphology of the lesions; however, it may also be because of the difficulty of detecting the pathogen. In the secondary stage, which is clinically extremely diverse, the diagnosis is confirmed serologically. There is a need for increased awareness of the symptoms and signs of acute infections, together with a willingness to consider the diagnosis of syphilis in patients with vague symptoms. An increasing number of diagnostic tests (both specific and nonspecific) are now available. However, in the absence of clinical symptoms or in cases with a low titer or inconsistent test results, diagnosis of syphilis can be difficult or even impossible. Treatment and follow-up should follow current guidelines designed for the involved area. In this article, the cutaneous manifestations of syphilis and their diagnostic and therapeutic management are described in detail.

Sunil Dogra MD, Assistant Professor, Dermatology, PGIMER, Chandigarh, India on March 2, 2008

Thanks for sharing this case. It is lichenoid secondary syphilis. Otherwise differential diagnosis may be considered - Penile Tinea or Bowen's Disease if it was more psoriasiform, however, unlikely in this case.

References:-
1. Lochner JC, Pomeranz JR. Lichenoid secondary syphilis. Arch Dermatol 1974; 109: 81–83.
2. Carbia SG, Lagodin C, Abbruzzese M et al. Lichenoid secondary syphilis. Int J Dermatol 1999; 38: 53–55.
3. Kang SH, Lee D, Park JH, Kang MS, Cho SH, Park SW. Scrotal eczemalike
lesion of secondary syphilis in an HIV-positive patient. Acta Derm Venereol. 2005;85:536-7.

Ted Rosen MD, Professor, Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA on March 2, 2008

Excellent case. My diagnosis based solely on morphology was secondary syphilis. This exophytic, plaque presentation is common with HIV co-infection. In the US, the yearly incidence of syphilis is up dramatically since 2001, primarily amongst MSM. We should also remember that there has been a worldwide resurgence of LGV (L2 serovar) in MSM; in the present "epidemic" (throughout Europe, in US and Australia), the patient presents with symptoms of proctitis, not with inguinal adenopathy as might be expected. Serovar specific PCR on rectal discharge specimens is available through the CDC.

Julian Manzur MD, Dermatologist, Cuba on March 2, 2008

Despite it is important to keep in mind the possibility of co-existence of two diseases, e.g.,syphilis and another disease, my first diagnosis in this patient is secondary (annular) syphilis.

Bhushan Kumar MD, Former Head of Dermatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India on March 3, 2008

Lichens of secondary syphilis in this region behave more like moist lesions of condyloma lata. If left untreated for a while they would have definitely become more succulent. Syphilis in HIV patients does not behave differently in response to adequate treatment. However, recurrences especially serological tests are more frequent.

Thamir Alkubaisi MD, Dermatologist, College of Medicine, Anbar, Iraq on Mar 6, 2008

Good pictures. Important to put in mind the great imitator ( secondary syphilis), and should remember that when there is one sexual transmitted disease you should look for others. One partner is preventive measure for all human beings.

Ashok Sharma MD, Consultant Dermatologist, Ministry of Health, Kuwait on March 6, 2008

In a fully worked-up case like this the diagnosis of lichenoid secondary syphillis is not in doubt. It reminds us constantly that syphillis is a great imitator lest we forget! Purely from clinical morphology of the lesions annular lichen planus and annular sarcoidosis appear to be valid differential diagnoses.

Ibrahim Misk MD, Jordan on Apr 30, 2008

Nice case. With such clinical picture we should do serology studies for syphilis to confirm clinical suspicion.