Chudomirova, Krasimira MD, PHD*; Chapkanov, Atanas MD†; Abadjieva, Tsvetana MD*; Popov, Stephan MD‡
Departments of *Dermatology and Venereology, †Abdominal Surgery, and ‡Psychiatry, Medical University, Plovdiv, Bulgaria
Correspondence: Krasimira Chudomirova, MD, PhD, 4A, Kresna Str, 4002 Plovdiv, Bulgaria. E-mail: email@example.com.
Received for publication June 18, 2008, and accepted October 3, 2008.
A 57-year-old heterosexual man presented with a 4-month history of apple-sized red-violaceous nodes and smaller infiltrates with central crusted ulcer in the presternal region and tumor-like lesions covered with normal skin on the lateral part of the chest. One node perforated spontaneously with drainage of cloudy purulent fluid. The patient was treated for primary syphilis more than 30 years ago. The diagnosis gummatous cutaneous tertiary syphilis was put on the basis of the clinical features, the positive syphilis serology, and the histopathlogical findings of skin biopsy specimen. The penicillin treatment lead to resolution of the skin infiltrates. The fact of the renaissance of the late forms of syphilis raises the importance of the timely and high quality differential diagnosis in order to prevent misdiagnosis and mistreatment.
WE REPORT A RARE CASE nowadays, with gummatous cutaneous syphilis in a 57-year-old male patient. In December 2006, tumor-like painless infiltrates appeared on the chest. In April 2007, the patient was hospitalized in a surgical clinic with the presumptive diagnosis malignant disorder. The patient was heterosexual with multiple sexual partners. He had a history of primary syphilis (ulcus durum of glans penis) treated with penicillin in 1972 and cerebral ischemic stroke in 1996. The patient reported disturbance of the voice since September 2006 and gradually decrease of the vision of the right eye since March 2007 resulting in vision loss.
Examinations revealed 2 apple-sized red violaceous nodes with soft consistency and a few smaller red-brownish infiltrates, some of them with central crusted ulcer in the presternal region, and 2 tumor-like infiltrates with firm-elastic consistency covered with normal skin on the lateral parts of the chest. One of the presternal nodes perforated spontaneously with drainage of cloudy purulent fluid. (Figs. 1, 2). Four lesions were removed.
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.
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