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Case Reports

Abstract

We present a case of a 23-year-old female with a 2-month history of a very pruritic rash that began on her abdomen. After becoming ill with COVID-19 the rash spread to the rest of her body, sparing palms, soles, groin, and buttocks.  She was given a 5-day course of prednisone from her primary care physician which eliminated the pruritus, however the rash continued to worsen. Two days after the onset of the rash, she got a new tattoo on her neck which became elevated. A shave biopsy of one of the papules on her right upper back was taken for histologic analysis.

H&E demonstrated effacement of the rete ridges, superficial dilated vessels, and diffuse granulomatous inflammation with giant cells, scattered lymphocytes, histiocytes and rare plasma cells. PAS, GMS, Fite and Brown-Brenn stains were all negative.  A treponema pallidum immunohistochemical stain revealed numerous spirochetes in the epidermis and throughout the dermis, within the granulomatous inflammation.

Granulomatous inflammation is more often associated with tertiary syphilis, but can rarely be seen in early secondary syphilis, with all reported cases of granulomatous secondary syphilis presenting in the first twelve weeks of infection. Unlike the more typical secondary syphilis presentation, granulomatous secondary syphilis does not involve the palms and soles.  The buttocks and groin are often spared as well, with predominant sites of involvement being the trunk, face, neck, and upper extremities.  Histology differs from classic secondary syphilis as well with rare, if any, plasma cells.  This case highlights an unusual presentation of secondary syphilis,