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

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.

Condyloma lata of the umbilicus: A case report highlighting the present syphilis emergency.

Syphilis is an ancient sexually transmitted infection that plagues communities across the United States and the world. Cutaneous syphilis has a wide variety of manifestations and presentations, and is notoriously difficult to identify clinically as a result. In this report, we describe the case of a 30-year-old patient with condyloma lata on the umbilicus, an extremely rare site for the presentation of these lesions. With the recent surge in syphilis infections nationwide, including congenital infections, this case underscores the urgent necessity for heightened syphilis awareness and suspicion among clinicians.

Cell and tissue interactions of Treponema pallidum in primary and secondary syphilitic skin lesions: an ultrastructural study of serial sections.

There are limited reports on the ultrastructure of syphilis skin lesions. The aim of this study has been to perform an electron microscopic investigation of the morphology and the tissue distribution of treponemes in primary and secondary cutaneous lesions. Three cases of primary syphilitic chancre and one case of secondary syphilis were included. Prominent epidermal abnormalities in the primary chancre and a perivascular inflammatory infiltrate in the secondary lesion were found by light microscopy. Ultrastructurally, spirochetes were located mainly in the blood vessel walls and dermal tissue of the chancre lesions. In the secondary syphilis case, spirochetes were more abundant between epidermal keratinocytes. Most of them adjusted to the intercellular spaces. Occasionally, the electron microscopy images were highly suggestive of an intracellular location. Both the ultrastructural and immunohistochemical examination of the primary and secondary syphilis lesions showed a paradoxical distribution of the causative microorganisms compared to the light microscopic changes. In addition, the ultrastructural findings strongly suggest that Treponema pallidum subspecies pallidum invades tissues, not only through an intercellular, but also through a transcellular pathway.

Comparative analysis of immunohistochemistry, polymerase chain reaction and focus-floating microscopy for the detection of Treponema pallidum in mucocutaneous lesions of primary, secondary and tertiary syphilis.

BACKGROUND: The incidence of syphilis is increasing in many parts of the world including a re-emergence in Western Europe and North America. Depending on the disease stage, direct detection of Treponema pallidum in mucocutaneous lesions of syphilis may be difficult and histopathological findings are not always straightforward. Thus, the correct histological diagnosis may be challenging. OBJECTIVES: Comparatively to evaluate the evidence for infection with T. pallidum by immunohistochemistry (IHC), polymerase chain reaction (PCR) and focus-floating microscopy (FFM). METHODS: A series of 86 paraffin-embedded skin biopsy samples from patients with primary, secondary or tertiary syphilis was assessed for detection of T. pallidum by IHC and FFM; 45 specimens were also investigated by a T. pallidum-specific PCR analysis. Histopathological reaction patterns and number and distribution of treponemes were studied, and all data were re-evaluated by clinicopathological correlation. RESULTS: Using a polyclonal antibody directed against T. pallidum, we detected the presence of T. pallidum by IHC in 42/86 (49%) samples [6/9 (67%) primary, 34/62 (55%) secondary and 2/15 (13%) tertiary syphilis]. T. pallidum-specific DNA was detected in 31/45 (69%) specimens [4/4 (100%) primary, 26/34 (76%) secondary and 1/7 (14%) tertiary syphilis]. In comparison, FFM analysis resulted in an overall detection rate of 82/86 (95%) [9/9 (100%) primary, 60/62 (97%) secondary and 13/15 (87%) tertiary syphilis]. Significant differences were observed concerning amount and distribution of organisms (epitheliotropic vs. endotheliotropic) in correlation to the three disease stages and to histopathological reaction patterns. CONCLUSIONS: FFM is a highly sensitive and specific method to detect T. pallidum in tissue from mucocutaneous syphilis lesions. Our results indicate that a combination of PCR and FFM, as the most sensitive approach, could provide an additional benefit for the histopathological diagnosis of (late) secondary and tertiary syphilis and may be helpful in cases where serological testing of T. pallidum antibodies has failed, but the clinical suspicion for syphilis remains.

Annular and arciform lesions of the palms as unique manifestations of secondary syphilis.

We describe a patient presenting with annular-arciform symmetric lesions of the palms as the unique manifestation of secondary syphilis. The polymorphism of skin lesions in secondary syphilis depends entirely on the degree of inflammatory infiltrate, the level of vascular involvement and the resulting ischemia of the skin. Besides the transient and diffuse maculo-papules (roseola syphilitica), secondary syphilis skin lesions may have different morphology and shape. It has already been reported that in cases of reinfections by Treponema pallidum the skin lesions may be arciform, as in our patient, and asymmetric. Indeed, previous syphilis may attenuate the clinical and laboratory manifestations of a new infection with T.pallidum, that occurs with less severe skin manifestations or presents as latent syphilis. However, to our knowledge, annular-arciform lesions of the palms as unique manifestations of secondary syphilis have never been described. Clinicians should be well trained to recognize the atypical presentations of syphilis, especially in patients who have already received a syphilis diagnosis, since its incidence is steadily increasing in Europe, especially in men having sex with men.

Syphilis: A Contemporary Clinicopathologic Assessment.

Syphilis is a sexually transmitted disease caused by the spirochetal bacterium Treponema pallidum that has been of public health concern for centuries. In the United States, it is currently a reportable disease and one which is recently generating increasing case numbers especially in at risk populations of immune deficiency and men who have sex with men. The present series examines biopsies from 13 patients collected over a 12-year period from a general hospital network in north suburban Cook County, Illinois. There were 13 patients (11 male: 2 female) with varied presentations, including primary ulcerated anogenital chancres, mucosal lesions, peculiar rashes, and alopecia. The reason(s) for biopsy were not clear from the clinical record, as a clinical consideration of syphilis was recorded in only 3 cases. Histologic examination of the mucocutaneous lesions encompassed a spectrum of findings including ulceration, psoriasiform hyperplasia, intense mixed band-like inflammation at the dermal-epidermal junction with a prominent plasma cell component. The contemporary availability of an effective immunostain is a valuable diagnostic adjunct. The organisms generally parallel the intensity of the inflammatory infiltrate but the distribution may vary and rarely, organisms may be absent despite serologic confirmation. Previous corkscrew morphology of the organism described ultrastructurally is reflected in the immunostained representation. Although the diagnosis of syphilis remains a clinical one in most cases, some patients will have unusual presentations and biopsies will be done. The awareness of the pathologist will facilitate prompt and effective treatment.

Reflectance confocal microscopy for the in vivo detection of Treponema pallidum in skin lesions of secondary syphilis.

BACKGROUND: Secondary syphilis is a diagnostic challenge that relies on microscopic and laboratory tests. OBJECTIVE: We sought to assess the usefulness of in vivo reflectance confocal microscopy (RCM) to detect Treponema pallidum in lesions suggestive of secondary syphilis. METHODS: Macular and papular skin lesions from 3 patients clinically suggestive of secondary syphilis were imaged by RCM and confirmed by skin punch biopsy. RESULTS: In all lesions RCM demonstrated elongated small bright particles with a spiral shape intermingled with the keratinocytes. These features corresponded with immunohistochemical findings that revealed several spirochetes infiltrating the epidermis. LIMITATIONS: Unlike immunohistochemistry, RCM did not visualize T pallidum in the dermis and vascular walls because of limited imaging depth. The specificity and sensitivity of this technique need to be assessed. CONCLUSION: RCM may be an effective diagnostic tool for in vivo real-time imaging of T pallidum in skin lesions of secondary syphilis, and seems to correlate well with immunohistochemistry.

A Young Boy with Persistent Nodules and Hoarseness: A Rare Presentation of Nodular Secondary Syphilis.

Syphilis is a venereal disease caused by treponema pallidum, historically known as "great mimicker" because of its variable presentations. Secondary syphilis usually presents with maculopapular or papulosquamous rash. Rare manifestations include papulonodular, annular and lichenoid lesions. Nodules are usually found in benign tertiary syphilis. We present a case of a young boy who presented with five months' history of nodular skin lesions and hoarseness of voice. Venereal disease research laboratory (VDRL) was initially negative owing to prozone phenomenon. However, histopathology was confirmatory and he responded to benzathine penicillin. We present this case because of rare clinical presentation with persistent nodular lesions, unusual age group, and negative initial VDRL test.