|Year : 2014 | Volume
| Issue : 2 | Page : 146-148
Annular lichenoid syphilis: A rare entity
Ananta Khurana1, Archana Singal1, Seema Gupta2
1 Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital (University of Delhi), New Delhi, India
2 Department of Pathology, University College of Medical Sciences and GTB Hospital (University of Delhi), New Delhi, India
|Date of Web Publication||9-Oct-2014|
86, Vikasheel Apartments, Sector 13, Rohini, New Delhi - 110 085
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Syphilis is a disease known for centuries, but still continues to be a diagnostic challenge as the myriad manifestations of secondary syphilis can mimic a lot many dermatological disorders. Lichenoid syphilis is an uncommon entity, reported only occasionally in the penicillin era. We present the case of a 32-year-old woman presenting with localized annular lichenoid lesions on the neck.
Keywords: Annular, lichenoid, syphilis
|How to cite this article:|
Khurana A, Singal A, Gupta S. Annular lichenoid syphilis: A rare entity. Indian J Sex Transm Dis 2014;35:146-8
| Introduction|| |
A 32-year-old married woman presented with complaints of itchy red rash on her forearms and nape of neck for 2 months. She was clinically diagnosed as polymorphic light eruption and started on mild potent topical corticosteroids and antihistaminics, along with instructions for strict photo protection and use of sunscreen. Her forearm lesions improved with this treatment, but lesions on the nape of neck had worsened with complaints of significant itching, when the patient came for follow-up 2 weeks later. Clinical examination at this point of time revealed presence of annular lichenoid plaques and few lichenoid papules [Figure 1]a. Mucosal examination revealed no abnormality. A skin biopsy was ordered from the lesion on the nape of neck, keeping differentials of annular lichen planus and sarcoidosis. The biopsy revealed acanthosis, and hyperkeratosis in the epidermis. A focal interface infiltrate composed of lymphocytes with a conspicuous presence of the plasma cells as well as eosinophils was seen within the dermis [Figure 2]a. There was also prominent endothelial inflammation with endothelial cell swelling and red blood cell extravasation [Figure 2]b. At places, complete obliteration of the vascular lumina (endarteritis obliterans) was seen, with presence of plasma cells in the vessel walls [Figure 2]b. Based on these findings, a possibility of syphilis was suggested by the pathologist. About a week later, patient reported to us with new lesions over her genitalia and groin. Examination revealed multiple skin coloured to pinkish, flat topped, moist appearing papules in the perianal region, labia majora, pubic region and groin folds, suggestive of condyloma lata [Figure 1]c. In addition, she had developed multiple hyperpigmented macules on both palms. Other mucosae were not involved. There was no evidence of generalized lymphadenopathy or hepatosplenomegaly. Husband was also examined but had no clinical evidence of syphilis. Dark ground illumination test performed from the wet lesions of condyloma lata revealed spiral spirochetes with characteristic motility. Venereal disease research laboratory assay came out to be positive in the titres of 1:256 for the patient and in 1:8 for her husband. Thus, a diagnosis of secondary syphilis (S2) was established. Both partners also had a positive Treponema pallidum magglutination test. Serology for HIV and hepatitis B was negative in both. Repeated questioning about the possible source of infection was not rewarding. Both patient and her husband were treated with a single shot of 2.4 million units of benzathine penicillin after sensitivity testing. All lesions in patient resolved completely within a span of 2 weeks [Figure 1]b and d.
|Figure 1: Annular lichenoid plaques on the nape of neck (a) subsiding completely 2 weeks posttreatment (b). Condyloma lata involving groins, labia majora and pubic region (c) with complete resolution post injection penicillin (d)|
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|Figure 2: Interface dermatitis with conspicuous presence of plasma cells and eosinophils (H and E, ×100) (a); prominent endarteritis obliterans with complete obliteration of the vascular lumina with plasma cell infiltrate (arrow) (H and E, ×400) (b)|
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| Discussion|| |
Syphilis continues to be a public health problem, with various studies showing a rise in its prevalence, in recent years, in India as well as in the west. ,,
Cutaneous signs are the commonest and most important manifestations of secondary syphilis, with up to 80% of patients developing lesions of the skin or mucous membranes.  A dermatologist needs to be aware of the protean mucocutaneous manifestations that secondary syphilis can present with, to avoid misdiagnosis of this infection.
Lichenoid eruptions in secondary syphilis have been reported since the prepenicillin era. However, they were believed to be caused by arsenicals, which formed the mainstay of treatment of syphilis in those days.  Jeerapaet and Ackerman were the first to report lichenoid histological changes in patients of S2.  In 1974, Lochner and Pomeranz established the clinical-histopathologic correlation for lichenoid lesions occurring in syphilis. 
In the penicillin era as well, lichenoid lesions have been reported, albeit occasionally. ,,, Most of these cases including the present case had associated pruritus, which is otherwise an unusual symptom in S2 per se.,, Annular lichenoid lesions are even rare and have been reported previously on only two occasions. , The localized annular lichenoid lesions may present as a diagnostic dilemma, more so when other features of secondary syphilis are absent, as seen on the first visit in the present case. In this situation, a clinician has to entertain other conventional differentials such as lichen planus, annular sarcoidosis and granuloma annulare. In addition, like secondary syphilis, all the aforesaid disorders may also show interface inflammatory infiltrate on histology. However, in the present case, the presence of profuse plasma cell infiltrate and prominent endarteritis strongly suggested a diagnosis of syphilis. Further, presence of eosinophils in the infiltrate as in the present case is of rare occurrence. Histology mimicking lichenoid drug eruption with the presence of eosinophils and high level civatte bodies has been described by Tang et al. 
| Conclusion|| |
The presence of lichenoid lesions in a sexually active individual not responding to conventional therapy should arouse the suspicion of secondary syphilis. A thorough and serial clinical examination and careful histological evaluation is pertinent to reach at the definitive diagnosis.
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[Figure 1], [Figure 2]