Indian J Sex Transm Dis Indian J Sex Transm Dis
Official Publication of the Indian Association for the Study of Sexually Transmitted Diseases
Indian J Sex Transm Dis
The Journal | Search | Ahead Of Print | Current Issue | Archives | Instructions | Subscribe | Login    Users online: 1293   Home Email this page Print this page Bookmark this page Decrease font size Default font size Increase font size


 
  Table of Contents  
LETTER TO EDITOR
Year : 2017  |  Volume : 38  |  Issue : 1  |  Page : 98-99
 

Secondary syphilis: An unusual presentation


1 Department of Dermatology, Katihar Medical College, Katihar, Bihar, India
2 Department of Dermatology, KPC Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Dermatology, College of Medicine and JNM Hospital, Kalyani, West Bengal, India

Date of Web Publication30-Mar-2017

Correspondence Address:
Dr. Anupam Das
“Prerana,” 19, Phoolbagan, Kolkata - 700 086, West Bengal
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7184.194318

Rights and Permissions

 



How to cite this article:
Kumar P, Das A, Mondal A. Secondary syphilis: An unusual presentation. Indian J Sex Transm Dis 2017;38:98-9

How to cite this URL:
Kumar P, Das A, Mondal A. Secondary syphilis: An unusual presentation. Indian J Sex Transm Dis [serial online] 2017 [cited 2019 Nov 19];38:98-9. Available from: http://www.ijstd.org/text.asp?2017/38/1/98/194318


Sir,

Salient mucocutaneous manifestations of secondary syphilis include condylomata lata, mucous patch, and patchy “moth-eaten” alopecia.[1] We hereby report an atypical presentation of secondary syphilis, wherein the patient did not have any other manifestation of the disease.

A 35-year-old male presented with multiple, itchy, violaceous papules and plaques on medial thighs bilaterally and on scrotum for 2 months [Figure 1]a. He had few similar lesions elsewhere too. There was a history of repeated unprotected sexual exposure with commercial sex workers in recent past. There was no history of any urethral discharge and burning micturition, rash on the body, or any constitutional symptom; however, there was a history of a painless ulcer on glans penis 4 months before presentation and the ulcer had healed in 4–5 weeks with self-medication with topical and systemic antibiotics. On examination, there were multiple, firm, moist, nontender, flat-topped papules and plaques on the scrotum and medial thighs. Few similar lesions were noted in the left axilla too. Of note, axillary lesions were remarkable for eroded surface [Figure 1]b. There was no rash on the body (including penis), and palms, soles, mucosae, scalp, and nails were unremarkable. He had multiple, discrete, nontender, shotty lymph nodes (about 1–3 cm in diameter) of the vertical and horizontal groups of superficial inguinal lymph nodes. The cervical, submental, suboccipital, and submandibular lymph nodes (about 1–3 cm) were also enlarged. The epitrochlear lymph nodes were not enlarged. A provisional diagnosis of condyloma lata was made, and lichen planus was considered as differential diagnosis. The hematological and biochemical investigations were normal. The venereal disease research laboratory test was reactive in a titer of 1:64. Serological testing for HIV was negative. A biopsy from the lichenoid plaque showed epidermal hyperplasia with a diffuse infiltrate consisting of lymphocytes, plasma cells, and histiocytes in the dermis. Epidermis was notable for focal aggregation of neutrophils [Figure 2] and [Figure 3]. Based on the history, examination findings, and serological results, a final diagnosis of condyloma lata was made. He was treated with a single dose of benzathine penicillin 2.4 million units (1.2 million units given in each buttock) after sensitivity testing. He was advised sexual abstinence and was asked to bring his wife for examination.
Figure 1: (a) Multiple violaceous papules and plaques on the scrotum and medial thighs and (b) multiple violaceous plaques with eroded surface on the axilla

Click here to view
Figure 2: Photomicrograph showing epidermal hyperplasia with a diffuse infiltrate consisting of lymphocytes, plasma cells, and histiocytes in the dermis. Note the focal aggregation of neutrophils in the epidermis (H and E, ×100)

Click here to view
Figure 3: Photomicrograph showing diffuse dermal lymphohistiocytic infiltrate. Note the presence of plasma cells (H and E, ×400)

Click here to view


Narang et al. reported two cases of secondary syphilis with annular lichenoid plaques on the scrotum associated with generalized lymphadenopathy, fever, and malaise.[1] Almost two decades ago, syphilis was initially missed in a Caucasian female who presented with an uncommon variant of syphilis, “lues maligna,” characterized by noduloulcerative skin lesions, fever, meningism, and a relapsing course.[2] To further add to the dilemma, there is a report of three patients who had secondary syphilis with severely pruritic skin lesions; and this presentation contradicts several modern literatures, wherein the lesions of secondary syphilis are described as nonpruritic.[3] Pruritus in secondary syphilis is more commonly noted in papular, follicular, and lichenoid variants.[4] Another interesting presentation was reported in an illustrative case of an apparently healthy 38-year-old man with a history of alopecia universalis; later developing extensive, mildly itchy, infiltrated annular verrucous lesions of the scalp, perioral, lumbar, perianal, and genital areas. Positive syphilis serology and magical response to penicillin confirmed a diagnosis of extensive annular and verrucous late secondary syphilis.[5] Thus, the presentation of syphilis, aptly described as “the great imitator,” can be extremely confusing at times.

Condyloma lata may be the sole manifestation of secondary syphilis, as in our case. Lesions usually progress from red, painful, and vesicular to “gun metal gray” as the lesions resolve. Their surface may be smooth, papillated, or covered with cauliflower-like vegetation. The common sites are the genital and anal areas where the condylomas are usually smooth and moist. Hypertrophic condyloma lata have been reported in the axillae, umbilicus, nape of the neck, and inner thighs.[6] Considering the recent decline in the incidence of syphilis, such lesions are likely to present infrequently. In some cases, as seen in our case, condyloma lata may be the only physical sign of syphilis; therefore, it is important that a high index of suspicion is maintained when evaluating lesions in patients at epidemiologic risk for syphilis. To conclude, clinical presentations might be misleading, and any suspicion should be dealt accordingly with appropriate investigations.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Narang T, De D, Dogra S, Kanwar AJ, Saikia UN. Secondary syphilis presenting as annular lichenoid plaques on the scrotum. J Cutan Med Surg 2008;12:114-6.  Back to cited text no. 1
    
2.
Patel A, Heath TC, Bowden FJ, Currie B. An unusual presentation of secondary syphilis in the Northern Territory. Australas J Dermatol 1994;35:23-7.  Back to cited text no. 2
    
3.
Chatterjee M, Gupta U, Gupta DK, Naik K. Lichenoid secondary syphilis. Indian J Sex Transm Dis 2004;25:44-6.  Back to cited text no. 3
    
4.
Cole GW, Amon RB, Russell PS. Secondary syphilis presenting as a pruritic dermatosis. Arch Dermatol 1977;113:489-90.  Back to cited text no. 4
    
5.
Pournaras CC, Masouye I, Piletta P, Piguet V, Saurat JH, French LE. Extensive annular verrucous late secondary syphilis. Br J Dermatol 2005;152:1343-5.  Back to cited text no. 5
    
6.
Fiumara NJ. Unusual location of condyloma lata. A case report. Br J Vener Dis 1977;53:391-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
Print this article  Email this article
 

    

 
  Search
 
  
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,766 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    References
    Article Figures

 Article Access Statistics
    Viewed1383    
    Printed48    
    Emailed0    
    PDF Downloaded76    
    Comments [Add]    

Recommend this journal