Computer axial tomography (CAT) and magnetic resonance imaging of the body and bone X-rays of the cranium and the extremities were normal. Atrophy of the right optical nerve, paralysis of the left recurrent nerve, left lateral haemiparalysis, and cognitive impairment were diagnosed. CAT and magnetic resonance imaging of the brain revealed multiinfarct vascular encephalopathy. Electroneurography demonstrated decreased conductivity of the left laryngeal superior nerve and the right hypoglossal nerve.
Blood tests (complete blood cell count and biochemical parameters) showed no abnormalities, with exception of neutropenia (neutrophils 48.5%), and elevated erythrocyte sedimentation rate 46 mm/hour. Cerebrospinal fluid presented with normal biochemical values.
Dark-field microscopy, microbiologic, and mycological examinations were negative. Ziel-Nielsen stain and Stein-Loewenstein culture were negative for Mycobacterium tuberculosis. Tuberculin skin testing and laboratory tests for HIV, hepatitis B, and hepatitis C viruses were also negative.
Histopathological examination of biopsy specimens from skin lesions revealed a dense lymphocytic and plasma cell infiltrate of the dermis with necrotic areas, granulomas composed predominantly of epithelioid cells and some multinucleated giant cells of Langhans' type (Fig. 3). Warthin-Starry stain was not done.
Syphilis blood serology before treatment was highly positive: VDRL (4+, 1:64), TPHA (4+, 1:40,960), and FTA-Abs (4+). VDRL test in CFS was not reactive, TPHA (2+, 1:5,120) and FTA-Abs (2+) were positive.
Penicillin G 24 MU/day was administered intravenously for 20 days and 2 doses of 2.4 MU benzathine penicillin G intramuscular injections were subsequently applied, 1 per week. The cutaneous lesions regressed in 2 weeks. Six months later the serological blood examination revealed VDRL (4+, 1:16), TPHA (4+, 1:20,480), and FTA-Abs (4+). The patient currently exhibits only residual scars on the site of the lesions.
Late syphilis is now a rare disease in Europe; however it seems to be increasing over the last decade.1 An increase of the number of infectious and asymptomatic cases and a concentration of cases in high risk groups was noted in Europe after 1990.2,3 The new cases are not adequately detected and their treatment is frequently implemented by nonprofessionals.4 These factors are a prerequisite for the raise of late syphilis which demonstrates often with unrecognized forms.5,6
We do not have any data about the duration of the penicillin treatment of the primary syphilitic infection and the follow-up of our patient. We could not exclude also a reinfection during the next years because of the multiple sexual contacts and unprotected sex of the patient. We assume a reactivation of the syphilitic infection.
Cutaneous tertiary syphilis is very rare and little known, the manifestations are nonspecific and may masquerade other diseases, i.e., syphilis is the “great imitator.”6–8 Therefore the physicians must keep a high index of suspicion regarding the possible diagnosis of syphilis, and exclude tuberculosis, deep mycosis, sarcoidosis, leishmaniasis, and benign and malign tumors,9 like in our case.
The diagnosis of late syphilis is based exceptionally on the serological examination. The specific tests are usually significant positive. VDRL test could be negative in one fourth of the cases.10 In our case, VDRL was highly positive and suggested active syphilitic infection. High reactive titers of VDRL in patients with tertiary syphilis have been reported also by others.5,11 The histopathological findings of the skin lesions were typical for gummatous syphilis.12 The histopathological examination is not crucial for the diagnosis. Although the diagnosis of gummatous cutaneous syphilis in our case was unambiguous, the neurologic abnormalities were difficult to classify and the diagnosis neurosyphilis is uncertain.
This case emphasizes that gummatous cutaneous syphilis still exists. The fact of the renaissance of the late forms of syphilis raise an importance of the timely and high-quality differential diagnosis to prevent misdiagnosis and mistreatment of the disease.
1. Waugh MA. Re-emergence of syphilis. Hosp Med 2000; 61:454–455.
2. Kent ME, Romanelli F. Reexamining syphilis: An update on epidemiology, clinical manifestations, and management. Ann Pharmacother 2008; 42:226–236.
3. Fenton KA, Breban R, Vardavas R, et al. Infectious syphilis in high-income settings in the 21st century. Lancet Infect Dis 2008; 4:244–253.
4. Chudomirova K, Mihajlova E, Ivanov I, et al. Congenital syphilis-missed opportunities for prenatal intervention. Sex Transm Infect 2002; 78:224–225.
5. Drobacheff C, Moulin T, Van Landuyt H, et al. Cutaneous tertiary syphilis with neurological symptoms. Ann Dermatol Venereol 1994; 121:34–36.
6. Sule RR, Deshpande SG, Dharmadhikari NJ, et al. Late cutaneous syphilis. Cutis 1997; 59:135–137.
7. Rocha N, Horta M, Sanches M, et al. Syphilitic gumma-cutaneous tertiary syphilis. J Eur Acad Dermatol Venereol 2004; 18:517–518.
8. Varela P, Alves R, Velho G, et al. Two recent cases of tertiary syphilis. Eur J Dermatol 1999; 9:371–373.
9. Sekkat A, Sedrati O, Derdabi D. La syphilis tertiaire cutanéo-muqueuse. Ann Dermatol Venereol 1994; 121:146–151.
10. Goh BT, van Voorst Vader PC. European guideline for the management of syphilis. Int J STD AIDS 2001; 12(suppl 3):14–26.
11. Pereira T, Fernandes JK, Vieira AP, et al. Tertiary syphilis. Int J Dermatol 2007; 46:1192–1195.
© Copyright 2009 American Sexually Transmitted Diseases Association
12. Crowson AN, Margo C, Mihm M Jr. Treponemal diseases. In: Elder DE, Elenitsas R, Johnson BL Jr, et al, eds. Lever's Histopathology of the Skin
. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:591–603.