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Case Reports

Abstract

Syphilis is a sexually and vertically transmitted bacterial infection caused by the spirochete, Treponema pallidum. Syphilis has been referred to as “the Great Mimicker” due to the myriad of clinical presentations that can be difficult to recognize. Syphilis is classically characterized histopathologically by perivascular infiltrates composed of lymphocytes, histiocytes, and plasma cells as well as endothelial cell swelling and proliferation. The histopathological findings of syphilis can be just as varied as the clinical presentations.

We describe a case of a 45-year-old male presenting with a two-month history of erythematous scaly papules and nodules spread diffusely on the face, scalp, trunk, penile shaft, arms, and legs. Punch biopsy revealed a lichenoid dermatitis with dermal granulomatous inflammation of histiocytes, plasma cells, and neutrophils. The granulomas were in a perivascular and perieccrine distribution. Immunohistochemical staining was positive for spirochetes within the granulomas. Rapid plasma reagin was positive with a titer >1:512. Treatment with intramuscular penicillin G benzathine was recommended.

Granulomatous syphilis is a rare presentation of secondary syphilis and is more commonly associated with tertiary syphilis. Granulomatous secondary syphilis can appear on the skin as lesions other than the typical nodules and papules including cysts, ulcers, or facial annular granulomas mimicking sarcoidosis. Being able to diagnose and treat syphilis is important to prevent serious late complications seen in tertiary syphilis such as neurosyphilis and cardiovascular lesions. Therefore, histological recognition of granulomatous secondary syphilis is of importance.