CD8-positive pseudolymphoma in lues maligna and human immunodeficiency virus with monoclonal T-cell receptor-beta rearrangement.

A 42-year-old Caucasian man suffered from disseminated plaques and ulcerated nodules for 6 weeks. He had weight loss and generalized lymphadenopathy. Underlying diseases were not known up till then. Based on a skin biopsy, the diagnosis of CD8-positive cutaneous T-cell lymphoma, type mycosis fungoides was made in a pathological reference center for lymphoma. A reproducible T-cell receptor (TCR)-beta rearrangement was detectable. Before starting therapy, a new biopsy was taken and the previous diagnosis was re-evaluated taking clinical images and symptoms into account. Based on both, the diagnosis of a CD8+ pseudolymphoma in lues maligna and human immunodeficiency virus was made. We highlight histopathologic clues for the correct diagnosis, and we emphasize the indispensability of clinical-pathological correlation. Furthermore, we discuss the differential diagnosis of CD8+ lymphoproliferative disorders.

Treponema pallidum ssp. pallidum identification by real-time PCR targetting the polA gene in paraffin-embedded samples positive by immunohistochemistry.

Syphilis is a systemic and sexually transmitted infection caused by Treponema pallidum ssp. pallidum. This spirochete causes different clinical and subclinical stages depending on the duration of infection and immune status of the host. Several tests have been developed for diagnosis, and are classified into direct and indirect methods. The first one includes dark field microscopy, direct fluorescent antibody test in fluids or tissue, and molecular biology techniques. In the indirect method (serologic), the routine tests are used, and are divided in two categories: non-treponemal and treponemal ones. The objective of this work was to identify T. pallidum ssp. pallidum in paraffin-embedded skin biopsies positive by immunohistochemistry, using conventional polymerase chain reaction (PCR) and quantitative real time PCR (qPCR). We included a sample of 17 paraffin-embedded biopsies. DNA was extracted and processed by conventional PCR and real-time PCR with a TaqMan® probe to identify the polA gene. Using PCR, 11 tested positive (64.7%) and 6 (35.3%) were negative. With qPCR and TaqMan® probe, 100% of samples tested positive. The minimum number of spirochetes detected in each sample was 2. With this work, we can conclude that qPCR is a fast and very accurate method for diagnosis of syphilis in tissue specimens.

Nodular tertiary syphilis in an immunocompetent patient.

Acquired syphilis can be divided into primary, secondary, latent, and tertiary stages. About 25% of patients with untreated primary syphilis will develop late signs that generally occur after three to five years, with involvement of several organs. The authors present an immunocompetent female who developed a tertiary stage syphilis presenting with long-standing nodular plaques.

Nodular tertiary syphilis in an immunocompetent patient

Abstract: Acquired syphilis can be divided into primary, secondary, latent, and tertiary stages. About 25% of patients with untreated primary syphilis will develop late signs that generally occur after three to five years, with involvement of several organs. The authors present an immunocompetent female who developed a tertiary stage syphilis presenting with long-standing nodular plaques.

Human immunodeficiency virus-positive secondary syphilis mimicking cutaneous T-cell lymphoma.

Malignant syphilis or lues maligna is a severe form of secondary syphilis that was commonly reported in the pre-antibiotic era, and has now reemerged with the advent of the human immunodeficiency virus (HIV) epidemic. However, the characteristic histopathological findings of malignant syphilis remain controversial. The aim of this case report was to clarify the clinical and histopathological findings of HIV-positive malignant secondary syphilis. A Japanese man in his forties complained of fever, skin lesions, headache, and myalgia without lymphadenopathy during the previous 4 weeks. The skin lesions manifested as erythematous, nonhealing, ulcerated papules scattered on his trunk, extremities, palm, and face. Although the skin lesions were suspected to be cutaneous T-cell lymphomas on histological analyses, they lacked T-cell receptor Jγ rearrangement; moreover, immunohistochemical analyses confirmed the presence of spirochetes. The patient was administered antibiotics and anti-retroviral therapy, which dramatically improved the symptoms. On the basis of these observations of the skin lesions, we finally diagnosed the patient with HIV-associated secondary syphilis that mimicked cutaneous T-cell lymphoma. The patient's systemic CD4+ lymphocyte count was very low, and the infiltrate was almost exclusively composed of CD8+ atypical lymphocytes; therefore, the condition was easily misdiagnosed as cutaneous lymphoma. Although the abundance of plasma cells is a good indicator of malignant syphilis on skin histological analyses, in some cases, the plasma cell count may be very low. Therefore, a diagnosis of malignant secondary syphilis should be considered before making a diagnosis of primary cutaneous peripheral T-cell lymphoma or lymphoma associated with HIV infection.

Malignant syphilis in a HIV infected patient.

We present a 47 year old female white HIV-1 infected patient with multiple painless rupioid skin lesions, a CD4 count of 155 cells/mm3, positive syphilis serology and a histopathology conspicuous for malignant syphilis. She could be successfully treated with Benzathine-Benzylpenicillin (Retarpen®) 2,4 Mega I.E., 3x intramuscularly in weekly intervals.

Malignant syphilis in an immunocompetent female patient

Malignant syphilis is an uncommon manifestation of secondary syphilis, in which necrotic lesions may be associated with systemic signs and symptoms. Generally it occurs in an immunosuppressed patient, mainly HIV-infected, but might be observed on those who have normal immune response. Since there is an exponential increase in the number of syphilis cases, more diagnoses of malignant syphilis must be expected. We report a case in an immunocompetent female patient.

Malignant syphilis in an immunocompetent female patient.

Malignant syphilis is an uncommon manifestation of secondary syphilis, in which necrotic lesions may be associated with systemic signs and symptoms. Generally it occurs in an immunosuppressed patient, mainly HIV-infected, but might be observed on those who have normal immune response. Since there is an exponential increase in the number of syphilis cases, more diagnoses of malignant syphilis must be expected. We report a case in an immunocompetent female patient.

Pathologically confirmed malignant syphilis using immunohistochemical staining: report of 3 cases and review of the literature.

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.

PCR testing for Treponema pallidum in paraffin-embedded skin biopsy specimens: test design and impact on the diagnosis of syphilis.

BACKGROUND: Syphilis, a chronic infection caused by Treponema pallidum, is a disease which is increasing in incidence, and thus more and more becoming a differential diagnosis in routine pathology. AIMS: To develop a PCR-based molecular assay for the detection of T pallidum in formalin-fixed, paraffin-embedded tissues, and evaluate its diagnostic power, especially in comparison with other ancillary methods (immunohistochemistry and Dieterle staining). METHODS: 36 skin biopsy specimens with the clinical and/or serological diagnosis of syphilis were evaluated by morphology, immunohistochemistry and silver staining. A semi-nested PCR assay targeting the T pallidum DNA polymerase A gene was designed and applied. Specificity of amplification was confirmed by direct sequencing of PCR products. RESULTS: Overall, the presence of T pallidum was detected in skin biopsy specimens in 20 cases, by immunohistochemistry, Dieterle staining, or PCR. Immunohistochemistry testing was positive in 17/35 cases tested, and Dieterle staining in 9/35 cases tested. In comparison, PCR testing was positive in 14/36 cases, and highly dependent on the tissue quality. When excluding cases with compromised DNA quality, PCR testing was positive in all cases except one, including three cases negative by immunohistochemistry and Dieterle staining. CONCLUSIONS: PCR testing is significantly more sensitive than silver staining, and provided that DNA quality is sufficient, at least as sensitive as immunohistochemistry for the detection of T pallidum in formalin-fixed, paraffin-embedded skin biopsy specimens. Therefore, it is a useful ancillary tool in the histological diagnosis of syphilis.

The localisation of treponemes and characterisation of the inflammatory infiltrate in skin biopsies from patients with primary or secondary syphilis, or early infectious yaws.

OBJECTIVE: To study the localisation of treponemes and to analyse the inflammatory infiltrate in biopsy specimens from patients with primary or secondary syphilis, or early infectious yaws. MATERIALS AND METHODS: Skin biopsies originating from human lesions of primary (29x) or secondary (15x) syphilis (Rotterdam), or early yaws (18x) (West Sumatra) were studied. Different histochemical and immunohistochemical detection methods were used in this study. RESULTS AND CONCLUSION: The histochemical silver staining method according to Steiner revealed the presence of T. pallidum in all cases of primary syphilis studied. In 10 out of 14 cases of secondary syphilis, treponemes were demonstrated. With an immunofluorescence staining technique (IF) using anti-T. pallidum antiserum raised in rabbits (a-Tp), T. pallidum was demonstrated in 28 out of 29 cases of primary syphilis, and in 14 out of 14 studied cases of secondary syphilis. The silver staining method and IF showed identical localisations of T. pallidum (mainly in the dermal-epidermal junction zone or throughout the dermis). Using a-Tp antiserum in the indirect immunofluorescence technique, T. pertenue could be demonstrated in the dermis more often than with Steiner silver staining. However, epidermotropism of T. pertenue in yaws specimens was remarkable, compared with more mesodermotropism of T. pallidum; numbers of T. pertenue in the dermis were limited in all specimens. The dermal inflammatory infiltrate in primary and secondary syphilis was composed mainly of lymphocytes and plasma cells. In most cases more T (CD3 positive) cells than B (CD22 positive) cells were present. Regarding T cell subpopulations, in primary syphilis, T helper/inducer (CD4 positive) cells predominated in 86% of cases. In secondary syphilitic lesions, numbers of T helper/inducer cells were less frequent than or equal to T-suppressor/cytotoxic (CD8 positive) cells in 60% of cases. Remarkably, in yaws specimens the inflammatory infiltrate consisted mainly of IgG, but also IgA and IgM producing plasma cells. T or B lymphocytes were scarce, which is in sharp contrast with findings in syphilitic lesions.

Protracted Treponema pallidum-induced cutaneous chancres in rabbits infected with human T-cell leukemia virus type I.

In a preliminary study, two of four rabbits infected with human T-cell leukemia virus type I (HTLV-I) demonstrated prolonged primary chancres following superinfection with Treponema pallidum, the causative agent of syphilis. Two rabbits inoculated with 1 x 10(7) HTLV-I-infected human MT-2 cells and two with infected rabbit cells from a line established in this laboratory (RLT-P), developed latent HTLV-I infection as detected by seroconversion 10 weeks after infection and by detection of HTLV-I sequences in the DNA of peripheral blood lymphocytes after amplification by polymerase chair reaction (PCR) 15 weeks after infection. The rabbits remained clinically normal and had normal blood counts. Six months after infection, the four HTLV-infected rabbits and two noninfected controls were challenged by the intradermal inoculation of 1 x 10(6) Treponema pallidum into eight sites on the shaved back. The lesions of two of the HTLV-I-infected rabbits had a time course similar to non-HTLV-I-infected controls and were completely healed by 4 weeks. The lesions of one of the other two rabbits with progressive disease began to heal about 7 weeks after T. pallidum challenge. The cutaneous lesions in the other rabbit remained dark-field positive and became a confluent eschar at 8 weeks; healing only after treatment with penicillin. Four months after the primary challenge none of the six rabbits previously challenged with T. pallidum had developed lesions after rechallenge and thus expressed chancre immunity. These results demonstrate that rabbits with latent HTLV-I infections may have defective cell-mediated immunity.

[A case of secondary syphilis simulating plasmocytoma]. / Sluchai vtorichnogo sifilisa, simulirovavshego plazmotsitomu.

A clinically unclear case is described of stomatitis with a long duration in a male of 28. Exfoliations in the region of the mouth angle were observed resembling pemphigus vegetans. Biopsy examination revealed a thick plasma cell infiltration which was considered to be an extramedullary plasmacytoma. However, a polyclonal composition of plasmacytes was found immunomorphologically producing immunoglobulins A, M and G with predominant production of IgG. This allowed rejection of neoplastic nature of the infiltrate, confirming its inflammatory origin and specific character. Serological tests (Wassermann, immunofluorescence test, in vitro immobilization test) confirmed the diagnosis of secondary recurring syphilis. Differential diagnosis of plasma-cell syphilid of skin and mucosal extramedullary plasmacytoma is under discussion.

Rabbit model of disseminated syphilis: immunoblot and immunohistologic evidence for a role of specific immune complexes in lesion pathogenesis.

Circulating immune complexes (CIC) containing Treponema pallidum proteins have been preliminarily implicated as inducers of a neutrophilic vascular reaction in early human cutaneous lesions of secondary syphilis. To clarify the role of specific CIC in producing cutaneous and renal lesions, 12 rabbits were studied at the following intervals after induction of disseminated syphilis: 20 days (4 rabbits: biopsies of normal and lesional skin for direct immunofluorescence (IMF) for (IgG, IgM, IgA, Clq, C3, C4), fibrin, and T. pallidum proteins; routine histology; and immunoblots of serum for CIC containing T. pallidum proteins); 21 days (4 rabbits: as at 20 days without IMF for T. pallidum protein); 23 days (4 rabbits: as at 20 days without IMF); 30 days (same 12 rabbits restudied with routine histology of normal and lesional skin; kidneys from 4 rabbits removed for routine, IMF, and electron microscopy (EM). Treponemal polypeptide antigen (MW-87 kd) was demonstrated in CIC from rabbits. Routine cutaneous histology showed evolution of lesions from an early neutrophilic vascular reaction to the typical lymphoplasmacytic reaction. IMF showed vessel-based immunoreactants in 3 of the 4 rabbits tested at 20 days and 1 of 4 at 21 days, and T. pallidum proteins in 3 of 4 rabbits at 20 days. Routine histology, IMF, and EM studies of glomeruli showed glomerular abnormalities, but no evidence of immune deposits containing specific T. pallidum protein. Skin and kidney studies of 4 controls were all negative. These data indicate a role for specific immune complexes in the pathogenesis of cutaneous lesions in this rabbit model.

Role of circulating immune complexes in human secondary syphilis.

Studies in animal models and in the glomerulonephritis of human secondary syphilis and results from in vitro assays have suggested a role for circulating immune complexes (CICs) in human secondary syphilis. Nine adult subjects with early secondary syphilis were studied. All patients tested had CICs on C1q-binding or Raji cell assays. Proteins previously described as Treponema pallidum-specific antigens were detected by radioimmunoblot techniques in CICs from all five subjects tested. Biopsy of early cutaneous lesions revealed immunoreactants (IgG, C3, and/or C1q) in three of nine subjects and treponemal antigen in six of eight subjects tested. Histamine was injected intradermally as a trap for CICs, and biopsy of these injection sites revealed immunoreactants in four of nine subjects and treponemal antigen in five of eight subjects tested. A neutrophilic vascular reaction consistent with CIC-mediated vessel damage was seen in three of nine lesions and six of nine histamine injection sites. Normal controls did not show these changes.

Cutaneous secondary syphilis: preliminary immunohistopathologic support for a role for immune complexes in lesion pathogenesis.

A circulating immune complex-mediated pathogenesis for lesions of secondary syphilis has been postulated. Textbook descriptions of a lymphoplasmacytic histopathologic picture have contradicted a role for circulating immune complexes in lesion pathogenesis. Four patients with early cutaneous lesions of secondary syphilis were studied. All four patients had serum Raji cell and/or Clq binding assay evidence for circulating immune complexes. Three patients showed a neutrophilic vascular reaction on histologic study of early lesions. The patients studied had immunofluorescence microscopic evidence of immunoreactant deposition in dermal blood vessels (4 hours) and/or a neutrophilic vascular reaction (24 hours) after intradermal histamine injection. Dieterle staining of lesional tissue from all patients showed the presence of treponemal organisms in dermal blood vessels. This new preliminary evidence adds some support to a circulating immune complex-mediated pathogenesis of cutaneous lesions in human secondary syphilis.

Adoptive transfer of anti-syphilis immunity with lymphocytes from Treponema pallidum-infected guinea pigs.

Spleen and lymph node cells taken from strain 2 and strain 13 guinea pigs at the peak of their primary immune response to cutaneous syphilitic infection could transfer partial protection to symptomatic disease to normal syngeneic recipients challenged with the Nichols strain of Treponema pallidum. These recipients of immune cells had significantly fewer treponemes disseminating to the regional lymph nodes and developed fewer and less severe cutaneous lesions that resolved faster than those in guinea pigs that had been infused with normal lymphoid cells. Immune donor cells also had the capacity to transfer specific delayed-type hypersensitivity responses for T. pallidum antigens. Both T and B cells were effective in conferring anti-syphilis immunity which was associated with the almost immediate development and persistence of substantially elevated levels of circulating anti-treponemal antibody in the protected recipients. Our findings in this adoptive transfer system provide the first direct experimental evidence implicating both cellular and humoral components of the immune response as important effector mechanisms in host resistance to the pathogenic spirochete causing venereal syphilis.