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Case Reports

Abstract

Lues maligna is a rare variant of secondary syphilis characterized by generalized ulcerative papules and nodules with necrosis and crusted borders. Constitutional symptoms often precede cutaneous manifestations. Lues maligna usually occurs in immunosuppressed patients with HIV co-infection. We present an uncommon case of lues maligna in an immunocompetent, HIV-negative patient. A 39-year-old female presented with painful, ulcerated lesions associated with cough and weight loss over the past month. Examination of the face, chest, back, and extremities revealed well-demarcated, round, erythematous, ulcerated plaques and nodules with surrounding violaceous borders and overlying rupioid scale. A biopsy was obtained from the left shoulder. Hematoxylin-eosin stain demonstrated necroinflammatory debris and intracorneal and intraepidermal neutrophils adjacent to ulceration. Within the superficial and deep dermis, there was extensive endothelial swelling and a dense nodular and perifollicular mixed inflammatory infiltrate composed of histiocytes, lymphocytes, neutrophils, and plasma cells. Spirochete immunohistochemical stain highlighted innumerable organisms throughout the dermis. These findings were consistent with lues maligna, which was confirmed by treponemal antibody and rapid plasma regain testing. The patient was started on doxycycline due to a penicillin shortage then received a dose of penicillin G intramuscular two days later. Despite its tendency to occur in HIV-positive patients, lues maligna should be considered in the differential for immunocompetent patients presenting with noduloulcerative lesions. As syphilis rates soar, clinicians are encountering an increasing number of such cases. Early diagnosis and treatment are essential given the need for HIV testing, association with visceral involvement including ocular and neurosyphilis, and public health implications.