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Malignant syphilis is a rare ulcerative variety. In the classical description of the disease, the absence of spirochetes in tissue samples was considered as a diagnostic criterion. We report 3 cases of malignant syphilis; in all of them, spirochetes were identified in cutaneous biopsy samples using immunohistochemical staining.

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SummaryHeparin use is associated with various cutaneous reactions, with the most common being immune-mediated skin lesions and bleeding complications. In this review, we compile the dermatological side-effects of heparin reported in the literature, and provide a clear approach to their adequate management. Heparin use and mechanism of actionHeparin (and its analogues) and warfarin are the traditional anticoagulants used for the prevention and treatment of thromboembolic disease. Table 1 shows a simplified classification of anticoagulants.Heparin is an indirect thrombin inhibitor that binds to anti-thrombin, converting this cofactor from a slow to a rapid inactivator of thrombin, factor Xa, and to a lesser extent, factors XIIa, XIa and IXa. Lowmolecular weight heparin (LMWH) drugs have less anti-thrombin activity than does unfractionated heparin (UFH). 1 Unfractionated heparin is used intravenously, and requires monitoring using the activated partial thromboplastin time (APTT). By contrast, LMWH is administered by subcutaneous injection, and the dose can be weightadjusted without monitoring. 1 Epidemiology of cutaneous adverse events associated with heparinOwing to under-reporting, the real incidence of heparininduced skin lesions is unknown.2 However, AEs are reported less often with LMWH than with UFH.3 In a recent prospective study, 2 the incidence and causes of heparin-induced skin lesions were evaluated in a large cohort of patients. An incidence of 7.5% was found, much higher than the 1-2% previously estimated. Delayed-type hypersensitivity reactions were found to be the commonest cutaneous side-effect related to heparin use. Most patients enrolled in the study received LMWH. Classification, aetiology and managementSkin lesions related to heparin use can be classified as: immune-mediated reactions, which covers (i) type I immediate hypersensitivity reactions; (ii) type IV delayed hypersensitivity reactions: (iii) skin necrosis; and non-immune-mediated reactions, covering (iv) bleeding diathesis and (iv) other, less common reactions (Table 2). Immune-mediated reactions Type I immediate hypersensitivity reactionsImmediate hypersensitivity reactions to heparins, 3-5 e.g. pruritus (including palmoplantar pruritus), urticaria ( Fig. 1), angio-oedema, conjunctivitis, rhinitis, bronchial asthma and anaphylaxis, are probably IgE-mediated. These reactions were first reported in the 1940s, after the introduction of heparin for clinical use, and were attributed to contaminant proteins and preservatives. They are now rare because of improved purification procedures.

BACKGROUNDOn December 31, 2019, the authorities of the People's Republic of China alerted of the appearance of a new type of virus of the Coronaviridae family, called SARS-CoV-2. Spain is among the most affected countries. Our aim is to describe the cases of COVID-19 during the first four months of the epidemic at