To better understand the cutaneous immune response to Treponema pallidum, we performed an immunohistologic study of skin biopsies from a total of 11 patients with secondary syphilis; biopsies from five persons infected with HIV-1 were included in the analysis to assess at the tissue level the impact of concomitant HIV-1 infection on disease expression. In all of the biopsies, staining for HLA-DR, a marker for cellular activation, was observed among infiltrating leukocytes, dermal vascular endothelial cells, and keratinocytes. Infiltrating mononuclear cells stained positively for CD4 or CD8, with CD4+ cells always being in the majority. Surprisingly, most of the CD4+ cells had histiocytic, rather than lymphocytic, morphologic characteristics. Immunostaining for CD14 confirmed that these cells were monocytic in origin, whereas immunostaining for CD3 revealed that the lymphocytes were predominantly CD8+ cytotoxic T cells. B cells were not detected despite the presence of variable numbers of plasma cells in all specimens. By immunofluorescence, all of the specimens demonstrated perivascular deposition of immunoglobulins, complement, or fibrinogen; linear staining at the dermal-epidermal junction also was observed in most of the specimens. No differences in immunocytochemical or immunofluorescence staining patterns were observed between the specimens from patients who were HIV positive and patients who were HIV negative. In addition to providing a more precise definition of the infiltrating cells in syphilitic lesions, our results, taken as a whole, indicate that cellular immune processes are largely responsible for the development of cutaneous manifestations during syphilitic infection and that coinfection with HIV-1 has little discernible effect on the cutaneous response to T. pallidum.

Eccrine syringofibroadenoma (ES) is generally regarded as a solitary benign adnexal neoplasm of the skin. Recently, the epithelial and stromal changes of this lesion have been recognized as being a reaction pattern in certain settings. We describe two individuals in whom this process was a manifestation of hidrotic ectodermal dysplasia. In both cases, the diagnosis had been missed for many years and the process had been thought to be a manifestation of an inflammatory dermatosis of the palms and soles. In both instances, other family members were found to be affected. Thus, ES may be manifested clinically as erythematous erosive plaques, especially of the palms and soles. It is important that clinicians be familiar with this disorder and be aware that it may exhibit unusual cutaneous manifestations.

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A 50‐year‐old Hispanic woman presented to the medical walk‐in clinic of a local community hospital complaining of shoulder pain. The problem had begun 9 months previously, and first manifested as dull right shoulder pain that developed after she carried a bag of groceries up one flight of stairs. A diagnosis of “muscle strain” and “arthritis” was made for which nonnarcotic analgesics were prescribed. The pain persisted, and 2 months later she was re‐evaluated and diagnosed with degenerative joint disease. An orthopedics consultation was sought for further evaluation. During this examination, she pointed out to the physician that she had a “lump in her shoulder,” but she was informed that this was of no consequence and that her complaints were due to arthritis. Roentgenograms of the right shoulder and thoracic spine were performed and determined to be within normal limits. Once again she attempted to control the pain with nonsteroidal anti‐inflammatory agents to no avail. Because the pain had become unbearable, she sought relief at the medical walk‐in clinic. Physical examination was remarkable for a solitary, skin‐colored, firm, deeply‐seated tumor measuring 3×4 cm located over the right posterior of the deltoid. The mass was exquisitely tender to palpation and was fixed to the underlying muscle. There was a full range of motion as well as good muscle strength of the shoulder, but movement of the arm in any direction was painful. The patient subsequently underwent a deep, partial excisional biopsy of the lesion, and a firm white tumor mass of about 3 × 3 cm in size was dissected away from the deltoid muscle. Although the majority of the tumor was excised, visible portions of the lesion were not removed because they were present deep within the bulk of the muscle. Histopathologic examination revealed a large, deeply‐seated poorly‐circumscribed fibrous proliferation containing areas in which there were numerous spindle cells arranged in fascicles ( Figs 1, 2, and 3). Neither cellular atypia nor mitotic figures were seen. The diagnosis of extra‐abdominal desmoid tumor was made. The patient subsequently underwent a wide re‐excision of the area and tolerated the procedure well, developing normal function of the arm following surgery, although there was slight persistent tenderness of the deltoid. Because of the known association of desmoid tumors with familial polyposis coli 1, a barium enema was performed. No colonic polyps were demonstrated. 1 Histopathology of desmoid tumor at scanning magnification. There is a large, poorly‐circumscribed, diffuse spindle cell proliferation that extends into the subcutis, muscle, and fascia (hematoxylin and eosin; original magnification, ×10) 2 At still higher magnification, abundant spindle cells in fascicles were appreciated and could be readily distinguished from collagen bundles. Note the elongated, wavy nuclei. No cellular atypia was seen (hematoxylin and eosin; original magnification, ×480) 3 At still higher magnification, abundant spindle cells in fascicles were...

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