Track: Case Reports

Topic: Infectious Diseases

Abstract:

Syphilis is on the rise in the United States, and early diagnosis and therapy would be paramount for limiting the spread. Atypical presentations of syphilis especially in the older population leads to a diagnostic pitfall. We hereby present three cases of nodular secondary syphilis with granulomatous inflammation in two patients.

All three patients present with non-tender rubbery papules and nodules involving the face and the trunk, with sparing of the palms and soles which is the reported presentation for nodular syphilis and one patient has involvement of the sole. Two patients were seen by multiple providers before a diagnosis of syphilis was rendered. On microscopic examination, two cases demonstrated a granulomatous pattern: one exhibited non-caseating granulomas, and the other, tuberculoid granulomas. The third case showed diffuse dermal infiltrate with mixed inflammation including lymphocytes, histiocytes and plasma cells. Ultimately, the presence of numerous plasma cells in all three cases and the clinical suspicion prompted additional investigation. Spirochetes were highlighted by a T. pallidum stain, confirming a diagnosis of syphilis.

Granulomatous inflammation is usually seen in tertiary syphilis but is a rare manifestation in secondary syphilis. With more florid granulomatous inflammation the treponemal stain could be weak or even negative creating a diagnostic pitfall. In these instances, high clinical suspicion and serologic confirmation would be key. Awareness of this rare clinical and histologic pattern underscores the importance of maintaining a high index of suspicion for syphilis, especially when a plasmacytic infiltrate is seen.

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Lina Nguyen, Medical Student