Abstract:

A 26-year-old male presented to an ambulatory care clinic in Saskatchewan, Canada with a three-month history of a gradually enlarging, 2 x 3 cm, fungating mass on the left anterior aspect of his neck and an otherwise unremarkable medical history. The patient was referred to a general surgeon given concerns for a cutaneous neoplasm and elected to have the mass excised for microscopic examination. Histologically, sections showed a predominantly ulcerated mass with some intact surface epithelium with long, slender rete appreciated at one lateral edge. There was brisk superficial and deep lymphoplasmacytic inflammation with well-established fibrosis at the deep edge. Immunohistochemical stain showed numerous spirochetes morphologically consistent with Treponema pallidum. This case illustrates an extremely uncommon clinical presentation of primary syphilis. Namely, the rare features of this case include the extragenital location on the neck, the fungating chancre that mimicked a cutaneous neoplasm, and the paucity of other associated clinical findings that typically accompany the case reports of extra-genital chancres including hosts with HIV or other immunocompromising conditions. Extragenital chancres with atypical clinical features have been reported previously. However, a case a primary pseudoneoplastic chancre has not been reported to our knowledge. Our patients chancre was completely excised, and he was subsequently treated with intramuscular Benzathine Penicillin G. This case represents a rare presentation of primary syphilis and highlights the remarkable variability in disease presentation. Specifically, this case was diagnostically challenging due to the noteworthy clinical presentation and paucity of clinical information at initial presentation. However, clinical details including patient age, sexual history, and high local incidence of syphilis are clues to inform a differential diagnosis of a large solitary extragenital chancre.

Financial Disclosure:
No current or relevant financial relationships exist.

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Bret Kenny, MEng