Abstract
An immunocompetent 48-year-old male underwent a planned right superficial temporal to middle cerebral artery bypass after two strokes in rapid succession. During post-operative monitoring, he was noted to have a few non-healing nodules with progressive ulceration which had been present for three months. A dermatology exam showed a 0.4 cm indurated, non-tender, hyperpigmented nodule with central ulceration and exudate on the right anterior thigh. Additional shallow erosions over the right shin and right nipple were present. A biopsy of the right thigh was obtained. Pathology showed deep dermal and subcutaneous infiltration composed predominantly of plasma cells. A Treponema pallidum immunohistochemical stain had scattered spirochetes within the infiltrate. PAS, AFB, and gram stains were negative. The findings demonstrated syphilitic dermatitis consistent with a gumma. He had a positive serology RPR and was treated with 3 doses of 2.4 million units IM at one-week intervals which is the treatment for both late latent and tertiary syphilis without CSF findings. He later had a positive CSF FTA-ABS and negative CSF VDRL. He was subsequently treated for neurosyphilis. Cutaneous gummas are rarely seen as tertiary syphilis is uncommon. However, there is a resurgence of syphilis in the United States. The rates of syphilis have continued to rise each year. From 2020 to 2021 there was a 32% increase in reported US cases of syphilis. This is a reminder to consider syphilis as a differential diagnosis in both immunocompromised and immunocompetent individuals.