Half a Century in Hiding: A Unique Case of Tuberculoid Leprosy with an Unprecedented Incubation Period.

BACKGROUND Leprosy, also known as Hansen's disease, is a neglected tropical disease with low prevalence in the United States. The disease's long incubation period can cause delayed presentation, and most affected individuals have a history of travel or work in leprosy-endemic regions. The immune response to Mycobacterium leprae determines the clinical characteristics of leprosy, with tuberculoid leprosy being characterized by well-defined granulomas and involvement of peripheral nerves. The recommended treatment is a combination of dapsone and rifampin for 12 months. CASE REPORT A 78-year-old man with a history of extensive travel to Africa and Asia 50 years ago, presented with a non-tender, non-pruritic, and hypopigmented skin lesion on his left knee. Biopsy results confirmed granulomatous inflammation and the presence of Mycobacterium leprae, leading to a diagnosis of tuberculoid/paucibacillary leprosy. The patient received dapsone and rifampin treatment, which resulted in symptom improvement. CONCLUSIONS The patient's long incubation period of 50 years between exposure and symptom onset is remarkable and possibly one of the longest reported for tuberculoid leprosy. It emphasizes the importance of considering leprosy in cases with an extensive travel history and long incubation periods. Our patient's case presented contradictory staining results, suggesting potential sampling variation or a rare mixed leprosy form. Based on his clinical findings, he was diagnosed with tuberculoid leprosy. Early diagnosis and treatment are crucial to prevent irreversible nerve damage and improve patient outcomes. Healthcare providers should be vigilant in acquiring a detailed travel history to facilitate early diagnosis and appropriate management of leprosy cases.

Cytokines profile in pure neural leprosy.

Introduction: Pure Neural Leprosy (PNL) is a form of this long time known disease that affects only the peripheral nervous system. Since it is a rare form of the disease, its pathophisiology is still poorly understood. Objective: Describe the cytokines profile in patients with PNL. Methods: 30 Patients diagnosed with PNL in the Souza Araujo Outpatient Clinic and with cytokines evaluated were selected. They were evaluated by neurologists and diagnosed after a nerve biopsy. Serum levels of IL-1 ß, IL-6, IL-10, IL-17, TNF, CCL-2/MCP-1, IFN-ϒ, CXCL-10/IP-10 and TGF-ß were evaluates at the moment of the diagnosis. Results: Neural thickening was a common clinical finding in this groups of patients. Small and medium sensitive fibers signs and symptoms were present in 92% of the patients and motor involvement in 53%. 43% of patients presented neuropathic pain and no one had neuritis TGF-beta, IL-17, CCl-2 and IP-10. CCL-2 levels were associated with demyelinating patters and IP-10 and IL-1o were associated with axonal patterns at NCS. Discussion: PNL patients' cytokine profile appears to be different of other clinical forms of leprosy, with the presence of cytokines described in both tuberculoid and lepromatous leprosy. High levels of CCl-2 may be related to the presence of silent neuritis as well as the presence of IL-10. PNL is unique a form of leprosy, therefore, understanding its immunological profiles essential to better understand the disease itself.

Skin Lesions, Foot Drop, and Hand Contractures.

A previously healthy individual in his 20s had 3 months of annular skin lesions, with numbness and paresthesia in the affected areas. Physical examination revealed multiple tattoos, bilateral palpable thickened auricular and ulnar nerves, and claw-hand deformity; test results for rapid plasma reagin, antinuclear antibodies, rheumatoid factor, acid-fast bacilli, mycobacteria, and fungi were negative, and biopsy did not identify Mycobacterium leprae. What is the diagnosis and what would you do next?

[Hansen's disease. Case report of tuberculoid leprosy in Chile]. / Enfermedad de Hansen. Comunicación de un caso de lepra tuberculoide en Chile.

Hansen's disease or leprosy is a chronic infectious disease caused by Mycobacterium leprae, mainly affecting the skin and peripheral nerves. In recent years, a better control of the disease has been achieved globally. However, in Chile the incidence of leprosy has continued to increase. We present a case of a 40-year-old patient Haitian nationality with lesions and histopathology compatible with tuberculoid leprosy. We discuss the importance of education on less prevalent diseases in Chile, in conjunction with a review of the pathophysiology, clinic, and classification of Hansen's disease.

Enfermedad de Hansen: comunicación de un caso de lepra tuberculoide en Chile / Hansen's disease: case report of tuberculoid leprosy in Chile

Resumen La enfermedad de Hansen o lepra es una enfermedad infecciosa crónica causada por Mycobacterium leprae, y que afecta principalmente la piel y nervios periféricos. En los últimos años, se ha logrado un mejor control de la enfermedad en forma global. Sin embargo, en Chile la incidencia de la lepra ha ido en aumento. Presentamos el caso clínico de un paciente de 40 años, haitiano, con lesiones e histopatología compatibles con una lepra tuberculoide. Se discute la importancia en la educación sobre enfermedades menos prevalentes en Chile y se hace una revisión sobre la fisiopatología, clínica y clasificación de la enfermedad de Hansen.

Abstract Hansen's disease or leprosy is a chronic infectious disease caused by Mycobacterium leprae, mainly affecting the skin and peripheral nerves. In recent years, a better control of the disease has been achieved globally. However, in Chile the incidence of leprosy has continued to increase. We present a case of a 40-year-old patient Haitian nationality with lesions and histopathology compatible with tuberculoid leprosy. We discuss the importance of education on less prevalent diseases in Chile, in conjunction with a review of the pathophysiology, clinic, and classification of Hansen's disease.

Follow-up assessment of patients with Pure Neural Leprosy in a reference center in Rio de Janeiro-Brazil.

INTRODUCTION: Pure Neural Leprosy (PNL) is a rare clinical form of leprosy in which patients do not present with the classical skin lesions but have a high burden of the disability associated with the disease. Clinical characteristics and follow up of patients in PNL are still poorly described in the literature. OBJECTIVE: This paper aims to describe the clinical, electrophysiological and histopathological characteristics of PNL patients, as well as their evolution after multidrug therapy (MDT). METHODS: Fifty-two PNL patients were selected. Clinical, nerve conduction studies (NCS), histopathological and anti-PGL-1serology were evaluated. Patients were also assessed monthly during the MDT. At the end of the MDT, all of the patients had a new neurological examination and 44 were submitted to another NCS. RESULTS: Paresthesia was the complaint most frequently reported by patients, and in the neurological examination the most common pattern observed was impairment in sensory and motor examination and a mononeuropathy multiplex. Painful nerve enlargement, a classical symptom of leprosy neuropathy, was observed in a minority of patients and in the motor NCS axonal injuries, alone or in combination with demyelinating features, were the most commonly observed. 88% of the patients did not present any leprosy reaction during MDT. There was no statistically significant difference between the neurological examinations, nor the NCS pattern, performed before and after the MDT. DISCUSSION: The classical hallmarks of leprosy neuropathy are not always present in PNL making the diagnosis even more challenging. Nerve biopsy is an important tool for PNL diagnosis as it may guide therapeutic decisions. This paper highlights unique characteristics of PNL in the spectrum of leprosy in an attempt to facilitate the diagnosis and management of these patients.

Primary neural leprosy: clinical, neurophysiological and pathological presentation and progression.

Disability in leprosy is a direct consequence of damage to the peripheral nervous system which is usually worse in patients with no skin manifestations, an underdiagnosed subtype of leprosy known as primary neural leprosy. We evaluated clinical, neurophysiological and laboratory findings of 164 patients with definite and probable primary neural leprosy diagnoses. To better understand the disease progression and to improve primary neural leprosy clinical recognition we compared the characteristics of patients with short (≤12 months) and long (>12 months) disease duration. Positive and negative symptoms mediated by small-fibres were frequent at presentation (∼95%), and symptoms tend to manifest first in the upper limbs (∼68%). There is a consistent phenotypic variability between the aforementioned groups. Deep sensory modalities were spared in patients evaluated within the first 12 months of the disease, and were only affected in patients with longer disease duration (∼12%). Deep tendon reflexes abnormalities were most frequent in patients with longer disease duration (P < 0.001), as well as motor deficits (P = 0.002). Damage to large fibres (sensory and motor) is a latter event in primary neural leprosy. Grade-2 disability and nerve thickening was also more frequent in cases with long disease duration (P < 0.001). Primary neural leprosy progresses over time and there is a marked difference in clinical phenotype between patients with short and long disease duration. Patients assessed within the first 12 months of symptom onset had a non-length-dependent predominant small-fibre sensory neuropathy, whilst patients with chronic disease presented an asymmetrical all diameter sensory-motor neuropathy and patchily decreased/absent deep tendon reflexes.

Pure neural leprosy or amyloid neuropathy? Systematic review and clinical case report.

OBJECTIVE: To review the literature and to report a clinical case with initial suspicion of pure neural leprosy and final diagnosis of amyloid neuropathy. METHODS: The study was conducted in two stages. In stage one, a systematic literature review was carried out, with searches performed in the PubMed, Medline, and Lilacs databases, as well as in the leprosy sectoral library of the Virtual Health Library, using the following descriptors: neuritic leprosy, pure neural leprosy, primary neural leprosy, pure neuritic leprosy, amyloid polyneuropathy, amyloid neuropathies, and amyloid polyneuropathy. The search was carried out on May 28, 2020. Clinical trials, cohort studies, cross-sectional studies, clinical cases, and case studies published in Portuguese, English or Spanish between 2010 and 2020 were included. Stage two reports a case with initial suspicion of pure neural leprosy. Laboratory tests, electroneuromyography, ultrasound, and biopsy of the sural nerve were requested. RESULTS: Twenty-three scientific texts were included. No publications were found that contained both topics together. The challenging diagnosis of pure neural leprosy and the possibility of using auxiliary resources in diagnosis were the most emphasized themes in the studies. In the clinical case, the patient's electroneuromyography showed sensitive and motor polyneuropathy of the lower limbs, which was predominantly sensory and axonal, symmetrical, of moderate intensity, and the mixed type (axonal-demyelinating). Ultrasonography of the sural nerve revealed changes in the contour of the deep fibular nerves; biopsy of the sural nerve showed an accumulation of amorphous eosinophilic material in the nerve path, and Congo red stain showed apple-green birefringence of the deposit under polarized light. The final diagnosis was amyloid neuropathy. CONCLUSIONS: The final clinical diagnosis was amyloid neuropathy. The diagnosis of pure neural leprosy in endemic areas in Brasil is still a challenge for the health system.

Pure neural leprosy or amyloid neuropathy? Systematic review and clinical case report

SUMMARY OBJECTIVE: To review the literature and to report a clinical case with initial suspicion of pure neural leprosy and final diagnosis of amyloid neuropathy. METHODS: The study was conducted in two stages. In stage one, a systematic literature review was carried out, with searches performed in the PubMed, Medline, and Lilacs databases, as well as in the leprosy sectoral library of the Virtual Health Library, using the following descriptors: neuritic leprosy, pure neural leprosy, primary neural leprosy, pure neuritic leprosy, amyloid polyneuropathy, amyloid neuropathies, and amyloid polyneuropathy. The search was carried out on May 28, 2020. Clinical trials, cohort studies, cross-sectional studies, clinical cases, and case studies published in Portuguese, English or Spanish between 2010 and 2020 were included. Stage two reports a case with initial suspicion of pure neural leprosy. Laboratory tests, electroneuromyography, ultrasound, and biopsy of the sural nerve were requested. RESULTS: Twenty-three scientific texts were included. No publications were found that contained both topics together. The challenging diagnosis of pure neural leprosy and the possibility of using auxiliary resources in diagnosis were the most emphasized themes in the studies. In the clinical case, the patient's electroneuromyography showed sensitive and motor polyneuropathy of the lower limbs, which was predominantly sensory and axonal, symmetrical, of moderate intensity, and the mixed type (axonal-demyelinating). Ultrasonography of the sural nerve revealed changes in the contour of the deep fibular nerves; biopsy of the sural nerve showed an accumulation of amorphous eosinophilic material in the nerve path, and Congo red stain showed apple-green birefringence of the deposit under polarized light. The final diagnosis was amyloid neuropathy. CONCLUSIONS: The final clinical diagnosis was amyloid neuropathy. The diagnosis of pure neural leprosy in endemic areas in Brasil is still a challenge for the health system.

Polar forms (TT and LL)

Leprosy is a spectral disease. Its two polar forms, tuberculoid (TT) and lepromatous (LL), are distinct presentations of the disease, both from a clinical and histopathological/bacilloscopic point of view. In this chapter, the histopathological characteristics that define the two polar forms (TT and LL), are presented, and their main differential diagnoses are discussed. These two forms also have significant differences in their treatment protocol. Histopathological recognition of both forms of the disease is important for choosing the correct treatment. Also, there are a large numbre of disease that can have a clinical presentation similar to the TT and LL forms of leprosy. In this context, histopathological examination is essential for defining the diagnosis of leprosy.

[Association of borderline tuberculoid leprosy and tuberculosis: A case report and review of the literature]. / Association d'une lèpre borderline tuberculoïde et d'une tuberculose : un cas et revue de la littérature.

INTRODUCTION: In metropolitan France, nearly 20 new cases of leprosy are diagnosed each year. The incidence of tuberculosis in France is 8/100,000 inhabitants and there are very few accounts of association of these two mycobacteria. Herein we report a case of co-infection with borderline tuberculoid (BT) leprosy and disseminated tuberculosis diagnosed in metropolitan France. PATIENTS AND METHODS: A male subject presented with diffuse painless infiltrated erythematous plaques. The biopsy revealed perisudoral and perineural lymphohistiocytic epithelioid cell granuloma as well as acid-alcohol-fast bacilli on Ziehl staining. PCR was positive for Mycobacterium leprae, confirming the diagnosis of leprosy in the BT form. The staging examination revealed predominantly lymphocytic left pleural effusion, right-central necrotic adenopathy without histological granuloma, negative screening for BK, a positive QuantiFERON-TB™ test, and a positive intradermal tuberculin reaction. The clinical and radiological results militated in favour of disseminated tuberculosis. Combined therapy (rifampicin, isoniazid, ethambutol and pyrazinamide) together with clofazimine resulted in regression of both cutaneous and extra-cutaneous lesions. This rare co-infection combines leprosy, often present for several years, and tuberculosis (usually pulmonary) of subsequent onset. The pathophysiological hypothesis is that of cross-immunity (with anti-TB immunity protecting against subsequent leprosy and vice versa), supported by the inverse correlation of the two levels of prevalence and by the protection afforded by tuberculosis vaccination. In most cases, treatment for TB and leprosy improves both diseases. Patients presenting leprosy should be screened for latent tuberculosis in order to avoid reactivation, particularly in cases where corticosteroid treatment is being given.

Peripheral nerve biopsy: a tool still needed in the early diagnosis of neural leprosy?

BACKGROUND: The early recognition of neural impairment in leprosy, especially in primary neural forms, represents a challenge in clinical practice and a peripheral nerve biopsy may be required for diagnostic confirmation. This study aims to characterize the epidemiological, clinical, electroneuromyographic, laboratory and histopathological aspects of patients undergoing peripheral nerve biopsy during investigation of primary neural cases in leprosy. METHODS: A total of 104 patients with peripheral neuropathy who were referred to a national reference centre for leprosy were biopsied from 2014 to 2018. All cases underwent clinical, laboratory, histopathological and electroneuromyographic evaluations. RESULTS: Of 104 biopsied patients, leprosy was confirmed in 89.4% (93/104). The biopsied nerves were the ulnar (67.8% [63/93]), superficial fibular (21.5% [20/93]), sural (8.6% [8/93]), radial (1.1% [1/93]) and deep fibular (1.1% [1/93]). Twenty-nine percent (27/93) presented histopathological abnormalities and 4.4% (4/93) presented acid-fast bacilli. Nerve and superjacent skin quantitative polymerase chain reaction were positive in 49.5% (46/93) and 24.8% (23/93) of cases, respectively. Patients with multiple mononeuropathy had a higher frequency of histopathological abnormalities (p=0.0077). CONCLUSIONS: This study reinforces peripheral nerve biopsy's role as an important tool in the investigation of primary neural cases, contributing to the early diagnosis and also reducing diagnostic errors and the need for empirical treatment.

Appropriately Selected Nerve in Suspected Leprous Neuropathy Yields High Positive Results for Mycobacterium leprae DNA by Polymerase Chain Reaction Method.

Identification of Mycobacterium leprae DNA by polymerase chain reaction (PCR) is a reliable and an affordable method to confirm leprosy. DNA from 87 nerve samples (61 from paraffin blocks and 26 fresh samples) was extracted. Mycobacterium leprae DNA was amplified by PCR from 80/87 (92%) specimens. Patients were seen over a period of 11 years (2007-2019), and leprosy was diagnosed based on clinical and characteristic histopathology findings. The clinical diagnostic possibilities were as follows: leprous neuropathy in 73/80 (91.3%), mononeuritis multiplex of unknown etiology in four (5.0%), vasculitic neuropathy in two (2.5%), and distal symmetric sensory motor neuropathy in one (1.3%). The biopsied nerves were as follows: superficial radial = 34 (42.6%), dorsal cutaneous branch of ulnar = 19 (23.8%), sural = 18 (22.5%), and superficial peroneal = 9 (11.3%), and corresponding neurological deficits were recorded in 77 (96.3%) cases. The histopathological diagnoses in total group were as follows: (borderline tuberculoid (BT) = 52, tuberculoid (TT) = 8, borderline lepromatous (BL) = 8, borderline borderline (BB) = 3, nonspecific inflammation = 3, healed/fibrosed = 4, and axonopathy = 2). Acid fast bacilli (AFB) was demonstrated in 11 (13.7%) samples. For comparison, 31 clinically and histopathologically defined non-leprous disease control nerves (inherited neuropathy = 20, vasculitis = 8, and nutritional neuropathy = 3) subjected to PCR were negative for M. leprae DNA. In most instances, there are multiple thickened peripheral nerves in suspected cases of leprosy, but neurological deficits pertaining to the thickened nerve are not as widespread. The current findings emphasize the importance of selecting the most appropriate nerve for biopsy to obtain a positive PCR result. We infer that clinical, histopathological, and PCR tests complement each other to help achieve a definitive diagnosis of leprosy particularly in pure neuritic leprosy and in leprous neuropathy with negative skin smears/biopsy.

[Atypical Localization of a Case of Leprosy in Lomé (Togo)]. / Localisation atypique d'un cas de lèpre à Lomé (Togo).

This was a 50-year-old woman with a selling activity living in Lomé who came for a consultation in March 2016 for a facial flushing that had been going on for 2 months without pain or pruritus. On examination, there was a single, erythemato-squamous closet of the right hemiface. There was no infiltration of the right ear. There was moderate cutaneous heat compared to the left hemiface which was without any lesion. Examination of nails, hair, palms and plants was normal. There was no hypertrophy of the peripheral nerves (superficial cervical plexus, ulnar, median). The face was not fixed. Complementary examinations noted a normal blood count and negative HIV status. Histology performed on a biopsy fragment concluded tuberculoid leprosy. The patient was first put on WHO multidrug therapy during 6 months. But one month after stopping this treatment, the lesions resumed. She was referred to a multibacillary leprosy protocol during one year. She had been seen 4 months after stopping treatment, without recurrence. It is important not to ignore leprosy in case of atypical erythema of the face even in the absence of other evocative signs and to perform a biopsy to the slightest doubt.

Il s'agit d'une femme de 50 ans, revendeuse, résidant à Lomé qui a consulté en mars 2016 pour une rougeur du visage évoluant depuis 2 mois sans douleur, ni prurit. À l'examen, on notait un placard unique érythémato-squameux de l'hémiface droit avec une bordure infiltrée. Il n'y avait pas d'infiltration du pavillon de l'oreille droite. Il y avait une chaleur cutanée modérée par rapport à l'hémiface gauche qui était sans aucune lésion. L'examen des ongles, des cheveux, des paumes et plantes était normal. On notait une absence d'hypertrophie des nerfs périphériques (plexus cervical superficiel, cubital, médiane). Le visage n'était pas figé. Les examens complémentaires notaient un hémogramme normal et une sérologie VIH négative. L'histologie réalisée sur un fragment biopsique a conclu à une lèpre tuberculoïde. La patiente a d'abord été mise sous le protocole de polychimiothérapie de l'OMS pendant 6 mois. Mais un mois après l'arrêt de ce traitement, les lésions ont repris. Elle a été remise sous un protocole de lèpre multibacillaire pour une durée d'un an. Elle a été revue 4 mois après l'arrêt du traitement, sans récidive. Il importe de ne pas méconnaître une lèpre devant un érythème atypique du visage même en l'absence d'autres signes évocateurs et de réaliser une biopsie au moindre doute.

Neuritic Leprosy; An Intriguing Re-visit to a Forbidden Ailment.

Leprosy is a chronic infectious disease that presents with varied manifestations. Pure neuritic leprosy is one of the rarest forms of the disease which is characterized by nerve involvement without the characteristic cutaneous stigmata. Eleven year old, healthy male presented with progressively increasing painful swelling at the medial aspect of the arm near to the right elbow joint with difficulty in extending right ring and little fingers at interphalangeal joint and numbness in the same region for last 1 year with no cutaneous abnormalities. Physical examination revealed 6x3 cm firm, tender lesion 3 cm proximal to the right elbow joint with positive tinel's sign, without signs of inflammation, along with characteristic claw hand deformity of right hand and atrophy of hypothenar and interossei muscle. Electro-diagnostic testing revealed findings consistent with a right ulnar axonal neuropathy above the elbow. Magnetic resonance imaging revealed well defined heterogeneously hyper intense linear lesion along the course of thickened ulnar nerve in the distal arm extending posterior to the medial condyle. It also showed an oval shaped lesion (2.1x1.0 cm) arising from the same segment of the nerve, without any bony or muscular involvement of that area. The patient underwent surgical exploration and ulnar nerve decompression with biopsy. Pathology revealed necrotizing granulomatous inflammatory acid fast bacilli stain negative lesion, which was histologically consistent with caseous abscess caused by tuberculoid leprosy, pathognomonic for Hansen's disease. He has been started on antibiotic therapy and is referred to leprosy center for further course of management. Pure neuritic leprosy, though rare, should be considered as differential diagnosis in cases presenting with peripheral neuropathy at leprosy-endemic areas. Prompt diagnosis and treatment is imperative to prevent permanent neurological injury.

Lepra tuberculoide como diagnóstico diferencial en placas de secundarismo sifilítico en contactos de paciente multibacilar. A propósito de un caso / No disponible

Dentro de los diagnósticos diferenciales de la lepra tuberculoide se citan la Sífilis secundaria, Tiña corporis, Granuloma anular, tuberculosis cutánea, entre otros. La sífilis es una enfermedad infectocontagiosa, sistémica, de transmisión predominantemente sexual, que en su larga evolución no interrumpida por tratamientos transcurre por dos periodos contrapuestos entre sí. Se trata de una paciente blanca, femenina, de 19 años, con antecedentes de salud, antecedente de ser contacto intradomiciliarios de primer orden de un paciente multibacilar, que acude a consulta de Dermatología por presentar lesiones desde hace varias semanas, las cuales describe como "empeines", que no pican ni causan molestias, que empezaban como "picazos de mosquito" y crecían paulatinamente. Unido a esto a presentó fiebre vespertina, cansancio, malestar general y cefalea, que las relacionó con la incubación de un proceso catarral. Durante el interrogatorio se recoge el antecedente que hace aproximadamente 5 meses presentó una lesión genital en forma de un "peladito" que desapareció sola y que su esposo también presentó una lesión genital similar antes que ella, que según refiere en su área de salud fue interpretado como tiña corporis por lo que habían iniciado tratamiento tópico con ketoconazol desde hacía una semana. Al examen dermatológico se constata cuadro diseminado constituido por lesiones anulares, con zona central de color más oscuro, con bordes bien definidos, papulosos, que en algunos se constatan costras hemáticas pequeñas, con diámetros que oscilan entre uno y cuatro centímetros, en número de menos de una decena, distribuidas en cara, V del escote, región proximal de los miembros. En la sífilis temprana, después que transcurre el período de segunda incubación y como tempestad en cielo despejado aparecen las manifestaciones del secundarismo sifilítico con lesiones en piel, mucosas, anejos y toma sistémica

Among the differential diagnoses of tuberculoid leprosy are among others, secondary syphilis, tinea corporis, granuloma annulare and cutaneous tuberculosis. Syphilis is an infectious, contagious, systemic disease of predominantly sexual transmission, which in its long evolution if not treated evolves through two periods opposed to each other. Here we describe the case of a 19-year-old white female patient with a history of health problems and a close contact of a multibacillary patient, who came to the Dermatology Department presenting lesions of several weeks of evolution, which she describes as "eczema", which do not sting or cause discomfort, and started as "mosquito bites" which gradually grew. In addition to this, she presented afternoon fever, fatigue, malaise and headache, which she related to the incubation of a catarrhal process. During the medical interview, she related that approximately 5 months ago she noticed a genital lesion she described as a "little problem" that disappeared alone and that before her husband already had presented a similar genital lesion that at her health center was diagnosed as tinea corporis and was prescribed topical treatment with ketoconazole for a week. The dermatological examination revealed a disseminated picture constituted by annular lesions, with a darker central area, with well-defined, papular edges, which in some cases showed small blood scabs. The diameters of the lesions, less than a dozen, ranging from one to four centimeters disseminated around the face, V of the neckline and proximal region of the limbs. In early syphilis, after the second incubation period and in form of a "clear-sky storm", the secondary syphilitic symptoms appear with lesions on the skin, mucous membranes, appendices and systemic dissemination