Syphilis the great pretender: when is cancer not cancer?

The number of cases of syphilis continues to rise in the UK, USA and elsewhere and may present to a variety of clinical specialties. We report a complex case of early acquired disseminated syphilis causing an ulceronodular rash (lues maligna), orchitis, osteitis and lung nodules in an immunocompetent man who has sex with men who presented to the genitourinary medicine clinic. Syphilis should be considered in the differential diagnoses of multiple clinical presentations and optimal management should involve multidisciplinary care.

Non-primary nail-plate syphilis in an HIV-infected patient.

A 37-year-old Caucasian male, HIV-infected (CDC A2) in 2012 and on antiretroviral therapy, presented for a follow-up visit. On physical examination, a barely discernible light-colored macular rash was observed on the trunk, not involving the palms and soles. However, clear maculo-papular lesions were present over the proximal volar aspect of both forearms. Furthermore, well-demarked purplish, opaque, rough, vertically ridged plaque-like lesions were observed over the proximal portions of fingernails. The patient reported that cutaneous and nail lesions had appeared about 2 months prior and that he had engaged in unprotected sex 5 months before. Serologic tests for syphilis resulted reactive. Intramuscular injection of benzathine penicillin G, 2.4 million units, was administered once a week for 3 weeks. One month after therapy, the rash was no longer present, and at 5 months, nail abnormalities had disappeared. The clinical findings, the serologic results, and the disappearance of skin and nail lesions after the administration of penicillin strongly suggest that this HIV-infected patient had secondary or early late syphilis with skin and nail-plate involvement. We are experiencing a resurgence of syphilis as well as an increase in unusual and/or forgotten clinical manifestations. Syphilis remains a diagnostically challenging disease.