Track

Case Reports

Abstract

It is well known that the incidence of syphilis is increasing in recent decades. The variety of clinical and histologic manifestations of secondary syphilis is notoriously broad. While tertiary syphilis is typically associated with a gummatous clinical appearance with findings of necrotizing or non-necrotizing granulomatous infiltrate in histologic sections, secondary syphilis may rarely present similarly. Here we present a case of clinically gummatous syphilis in a 33-year-old male with a five-month history of worsening painful and pruritic diffuse erythematous and crusting nodules and papules involving the face, trunk, and all four extremities. Past medical history included previously diagnosed and treated syphilis and new diagnosis of HIV, along with homelessness and high-risk sexual behavior. Imaging workup demonstrated numerous visceral and skeletal lesions, including an abdominal mass which was biopsied to reveal a CD10-positive B-cell lymphoma with aggressive features. Punch biopsy of a cutaneous nodular lesion revealed dense superficial and deep non-necrotizing granulomatous lymphohistiocytic infiltrate with epithelioid histiocytes and infrequent plasma cells. Spirochete immunohistochemical stain was negative, as were special stains for fungi and mycobacteria. Given that spirochete immunohistochemical stains may have decreased sensitivity in granulomatous syphilis lesions, molecular testing was obtained on the formalin-fixed paraffin-embedded skin biopsy tissue. Nucleic acid amplification test (NAAT) for Treponema pallidum DNA was positive, confirming the diagnosis of granulomatous syphilis. We present this case not only to highlight this rare manifestation of noduloulcerative granulomatous secondary syphilis, but also to underscore the histopathologic diagnostic challenges of this presentation.