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 Table of Contents  
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 55-56

Granulomatous syphilis: An atypical presentation

Department of Dermatology, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka, India

Date of Web Publication13-Jun-2019

Correspondence Address:
K M Prathima
Department of Dermatology, BGS Global Institute of Medical Sciences, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdpdd.ijdpdd_61_18

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How to cite this article:
Sriram R, Okade R, Prathima K M. Granulomatous syphilis: An atypical presentation. Indian J Dermatopathol Diagn Dermatol 2019;6:55-6

How to cite this URL:
Sriram R, Okade R, Prathima K M. Granulomatous syphilis: An atypical presentation. Indian J Dermatopathol Diagn Dermatol [serial online] 2019 [cited 2023 Mar 22];6:55-6. Available from: https://www.ijdpdd.com/text.asp?2019/6/1/55/260194


Syphilis is a disease caused by a microaerophilic spirochete, Treponema pallidum. It is contracted through intimate contact with an infected individual.[1] The classic, primary chancre of syphilis is painless and is often overlooked by the patients. A significant proportion of these patients go on to develop secondary syphilis, which characteristically presents with generalised asymptomatic skin rash forcing the affected patients to seek medical attention.[2] Histopathological features of secondary syphilis may mimic many other inflammatory dermatoses, thus creating a diagnostic challenge for the dermatologist and dermatopathologist alike.[3] Here, we present an unusual histopathological presentation of secondary syphilis.

A 45-year-old male presented with a history of generalized rash of 1month duration. It initially began over the chest and abdomen as asymptomatic pink lesions which then spread to involve back, and upper part of arms and neck. He denied any history of extramarital sexual contact. The physical examination revealed multiple edematous, erythematous plaques involving chest, abdomen, back,- upper limbs, and neck [Figure 1]a and [Figure 1]b Tenderness was present on pinhead prick suggestive of Buschke- Ollendorff sign. There were no oral ulcers, genital lesions, palmar, plantar lesions, and lymphadenopathy. Biopsy revealed superficial and deep dermal, perivascular, and periadnexal inflammatory infiltrates, with accentuation of inflammatory infiltrate around small- caliber nerve fibers [Figure 2], [Figure 3], [Figure 4], [Figure 5]. The inflammatory infiltrate composed predominantly of epithelioid cells, plasma cells and scattered lymphocytes. Epidermis was unremarkable. Acid- fast bacilli stain was negative. Fite Faraco was negative. Investigations revealed complete blood count was normal, rapid plasma reagin (RPR) was non- reactive, ANA was negative and HIV was non reactive. As the inflammatory infiltrate was predominantly composed of plasma cells, RPR was repeated in serial dilutions keeping in mind prozone phenomenon. RPR titer was positive with titer of 1:256. TPHA was reactive with a titer of 1:1064. This prompted us to ask for sexual history again. He recalled having unprotected sexual intercourse and also a painless genital ulcer which resolved by the time skin lesions erupted. He was treated with single dose of 2.4million units of benzathine penicillin intramuscularly in divided doses. Repeat titer of RPR after 3 months was 1:32. The patient responded by partial resolution of lesions, after which we lost follow up. Ophthalmological examination was normal. No neurological symptoms were present.
Figure 1: (a) Multiple edematous, erythematous plaques on the neck, chest, and abdomen. (b) Multiple edematous, erythematous plaques on back

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Figure 2: Dense perineural infiltrate of lymphocytes and plasma cells along with epithelioid cell granulomas (H and E, ×40)

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Figure 3: Epithelioid cell granulomas along with giant cells along the nerve bundles (H and E, ×100)

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Figure 4: Perivascular plasma cell infiltrates (H and E, ×100)

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Figure 5: Epithelioid cell granulomas along with giant cells along the nerve bundles (H and E, ×100)

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The clinical differential diagnoses for a widespread erythematous, papulo-nodular skin eruption comprises of cutaneous lymphoid hyperplasia, Sweet's syndrome, lymphoproliferative diseases, histiocytoses, metastatic melanoma or carcinoma; infections such as lepromatous leprosy, other mycobacterial infections and disseminated deep fungal infections; and granulomatous processes such as disseminated granuloma annulare, sarcoidosis and connective tissue disorders such as scleromyxedema and lupus erythematosus.[4]

The cases showing epithelioid and palisading granulomas are nearly universally accompanied by lymphohistiocytic infiltrate in a predominantly perivascular and periadnexal distribution. Lee et al. and Rysgaard et al. reported similar cases of granulomatous syphilis.[3],[5] While at least scattered plasma cells were seen in all cases, our case had plenty of plasma cells. Although endothelial swelling and proliferation have historically been reported as a classic histopathological finding in the lesions of secondary syphilis, endothelial swelling was described in a minority of granulomatous cases.[5]

The granulomas are often organized in a T shape or candelabra- like pattern with close opposition to epidermal-dermal junction along the papillary dermal vasculature, and extension into the reticular dermis along follicular and eccrine structures, similar to our case.[5]

These findings suggest that dermatologists should consider the diagnosis of secondary syphilis in cases of dermal-based granulomatous inflammation with plasma cells.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Dave S, Gopinath DV, Thappa DM. Nodular secondary syphilis. Dermatol Online J 2003;9:9.  Back to cited text no. 1
Little JW. Syphilis: An update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100:3-9.  Back to cited text no. 2
Rysgaard C, Alexander E, Swick BL. Nodular secondary syphilis with associated granulomatous inflammation: Case report and literature review. J Cutan Pathol 2014;41:370-9.  Back to cited text no. 3
Balagula Y, Mattei PL, Wisco OJ, Erdag G, Chien AL. The great imitator revisited: The spectrum of atypical cutaneous manifestations of secondary syphilis. Int J Dermatol 2014;53:1434-41.  Back to cited text no. 4
Lee GL, Gru AA, Wong HK, Nagarajan P. Granulomatous syphilis: A pattern to remember. Case report and review of literature. Clin Microbial 2015;4:184.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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