Nodular secondary syphilis with associated granulomatous inflammation: case report and literature review

Abstract

A 62‐year‐old male presented with a 10‐day history of a diffuse, erythematous papular rash sparing the palms and soles. Histopathologic examination of a skin lesion showed loose non‐caseating granulomas in a lymphoplasmacytic background. Scattered spirochetes were identified by Treponema pallidum immunohistochemistry, in keeping with a diagnosis of secondary syphilis. Granulomatous inflammation in secondary syphilis is uncommon. A review of the literature reveals that the majority of prior reported cases of granulomatous secondary syphilis share similar characteristics to this case; namely, a papular or nodular clinical presentation, sparing of the palms and soles, and collections of epithelioid histiocytes with associated lymphocytes and variable numbers of plasma cells.

Papulonodular Secondary Syphilis Presenting as Multiple Distinct Cutaneous Lesions in an HIV-Positive Transgender Woman

“…Previous reports identified follicular, psoriasiform, vesicular, corymbiform, and lichenoid lesions in association with secondary syphilis [3]. Manifestations of secondary syphilis, including cutaneous presentations, are particularly diverse, leading clinicians in the pre-antibiotic era to refer to syphilis as the “great imitator” [2]. …”

“…Despite a decline of syphilis towards the end of 20th century, the rates of primary and secondary syphilis have increased by 15.1% since 2013 [2, 12]. The increase in the disease burden among the population may parallel an increase in atypical syphilitic presentations.…”

“…Syphilis, defined by primary, secondary, latent, and tertiary stages, is the result of an infection by the microaerophilic spirochete Treponema pallidum , either through sexual contact or congenitally from mother to fetus [1, 2]. Primary syphilis is characterized by the emergence of a painless red papule that ulcerates into the classic chancre [3].…”

“…Unlike the indolent lesion of primary syphilis, the generalized mucocutaneous skin lesions associated with secondary syphilis often lead patients to seek clinical attention [2]. …”

IFNγ Enhances CD64-Potentiated Phagocytosis of Treponema pallidum Opsonized with Human Syphilitic Serum by Human Macrophages

“…Syphilitic lesions in all stages of disease contain a rich cellular infiltrate, composed primarily of lymphocytes, plasma cells and macrophages, accompanied by vasculopathic changes of varying severity (6, 7) capable of giving rise to a wide variety of histological patterns, including granulomata (8). Immunocytochemical analysis has revealed that the relative proportions of T cell subsets shifts from predominantly CD4 + T cells in genital ulcers to a predominance of CD8 + T cells in SS lesions (7, 9).…”