Abstract:

A 69-year-old man with a history of follicular lymphoma presented to the dermatology clinic with a 3-month history of a non-painful, non-pruritic eruption of pink-to-violaceous dermal nodules on his upper trunk and upper extremities with sparing of the face, scalp, palms, and soles. He also endorsed recent onset of blurry vision. Skin biopsy of two separate lesions were similar and revealed a dense superficial and deep perivascular atypical lymphocytic infiltrate with admixed plasma cells, histiocytes, and eosinophils. The atypical lymphocytes were hyperchromatic with small/medium sized nuclei and showed expression of CD3, a normal ratio of CD4/CD8 (4:1), retained CD2 and CD5, and partial loss of CD7. Some scattered cells expressed CD30, PD1, BCL-6, and ICOS. Interestingly, EBV-via in situ hybridization was positive in a few cells, though blood PCR was negative. TCR-rearrangement showed an identical TCR-gamma clone between both biopsies. The constellation of findings was worrisome for a lymphoproliferative disorder, and the aforementioned immunophenotype was in keeping with angioimmunoblastic T-cell lymphoma. However, excisional biopsy of an enlarged left axillary node was consistent with a reactive process. The patient was subsequently seen by ophthalmology and diagnosed with acute anterior uveitis. RPR was reactive and CSF studies showed findings consistent with a diagnosis of neurosyphilis. A Treponema pallidum immunostain of the skin biopsies was performed upon re-review, and was diffusely positive for spirochetes at the dermal-epidermal junction and within injured vessels. The patient was treated with penicillin G with near resolution of his skin lesions. This case highlights the unusual ability of syphilis to mimic a T-cell lymphoma with matching clones across two different biopsy sites. To our knowledge, this has not been reported in the literature.

Financial Disclosure:
No current or relevant financial relationships exist.

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Lauren Yi, MD