Letters to the Editor

Disseminated nodular and granulomatous secondary syphilis Dear Editor, Syphilis is a clinically important microbial disease which has a broad spectrum of clinical manifestations. We report a young man who presented with a widespread nodular eruption, showing a granulomatous response on histopathology. A 32-year-old man was admitted with multiple nodules on the trunk and extremities of 3 months’ duration. Two months after onset, generalized brownish-red patches appeared on the trunk and extremities. There were associated low-grade fever and sore throat. He admitted to having active unprotected sexual contact with a partner. He denied any visible genital ulceration. Physical examination revealed violaceous nodules and granulomatous lesions with adherent crusts on the face, trunk and extremities (Fig. 1a). Generalized, brownish-red, scaly patches were found on his trunk and extremities (Fig. 1b). The palms, soles, genitalia and mucous membranes were spared. There was no lymphadenopathy. Skin biopsy was taken from a nodule lesion. Histopathological examination revealed diffuse infiltration of plasma cells, lymphocytes, histiocytes and a few multinucleated giant cells through the entire dermis (Fig. 1c). Rapid plasma reagin (RPR) test was positive with a titer higher than 1:32. Treponema pallidum particle agglutination test was also positive. Anti-HIV antibodies were absent. The diagnosis of secondary syphilis was made. The patient was treated with 2.4 million of units benzathine penicil-

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lin by i.m. injection weekly for 3 weeks. Obvious flattening of all lesions was observed within 2 weeks with a decrease in brownish-red patches. The RPR titer showed a fourfold fall at the end of 3 months. In the past few years, sexually transmitted diseases have substantially increased in China. Currently, syphilis is among the top five most common notifiable infectious diseases.1 According to the reports of the Chinese Center for Disease Control and Prevention, there was a 137.81% increase in registered syphilis incidence in 2012 compared to 2006. The incidence of registered syphilis rose to 30.44/100 000 in 2012. Secondary syphilis is a result of the hematogenous or lymphatic dissemination 4–10 weeks after initial infection. The most common cutaneous presentation of secondary syphilis is a generalized, non-pruritic, symmetrical, macular eruption that is purple, pink or coppery-brown in color. Secondary syphilis may rarely present as nodules and plaques.2,3 In our case, disseminated nodules with no involvement of mucous membranes were seen at the onset, and generalized typical patches subsequently developed in the skin. Previous studies suggested that formation of dermal granulomatous foci is correlated with duration of the eruption. In eruptions of 2–4 months’ duration, granulomatous foci were common, and they were consistently present in older untreated lesions.4 In our patient, the biopsy was taken from the nodule lesion of 3 months’ duration. Histological examination revealed the formation of typical granulomatous foci. At this stage of the disease, non-specific and specific treponemal tests should be reactive. The diagnosis of secondary syphilis in our case was accomplished by the histopathological patterns, positive screening and confirmatory serological tests. The differential diagnosis of nodular syphilis should include leprosy, sarcoidosis, lymphoma, lymphomatoid papulosis and pseudolymphoma.5

CONFLICT OF INTEREST:

None.

Jie LIU, Donglai MA Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Figure 1. (a) Multiple, violaceous, ellipse nodules with erosions and adherent crusts on the face and neck. (b) Generalized, well-defined, brownish-red, scaly patches with multiple nodules on his trunk. (c) Diffusely infiltrated composed of plasma cells, lymphocytes, histiocytes and a few multinucleated giant cells through the entire dermis (hematoxylin–eosin, original magnification 9100).

doi: 10.1111/1346-8138.12415

REFERENCES 1 Zhang L, Wilson DP. Trends in notifiable infectious diseases in China: implications for surveillance and population health policy. PLoS ONE 2012; 7: e31076.

Correspondence: Donglai Ma, M.D., Ph.D., Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China. Email: [email protected]

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Letters to the Editor

2 Xu XG, Zhang YQ, Xiao T, Chen HD. Localized granulation tissue-like nodules: an unusual cutaneous presentation of secondary syphilis. J Dermatol 2011; 38: 1–2. 3 Jang YH, Sim JH, Kim YC, Lee ES. Single nodular lesion on the scalp: a quiz Diagnosis: nodular secondary syphilis. Acta Derm Venereol 2011; 91: 491–494.

4 Abell E, Marks R, Jones EW. Secondary syphilis: a clinico-pathological review. Br J Dermatol 1975; 93: 53–61. 5 Moon HS, Park K, Lee JH, Son SJ. A nodular syphilid presenting as a pseudolymphoma: mimicking a cutaneous marginal zone B-cell lymphoma. Am J Dermatopathol 2009; 31: 846–848.

Granulomatous isotopic response possibly to herpes zoster in childhood Dear Editor, An 11-year-old otherwise healthy boy complained of a symptomless eruption on the back, of a few months’ duration. Phys-

ical examination showed a brownish, infiltrative plaque on the right upper back (Fig. 1a). He denied having a painful eruption on this site previously, and his mother did not recognize the

Figure 1. (a) Infiltrative, well-circumscribed, brownish plaque on the right upper back. (b) Histological features showing inflammatory infiltrate interstitially distributed in the dermis (hematoxylin–eosin [HE], original magnification 940). (c) Higher magnification reveals interstitial histiocytes arranged in an array between the collagen bundles (HE, 9200), which were immunoreactive for (d) CD68 (9200) as well as (e) CD163 (940). (f) Varicella zoster virus immunostain show a positive localization in the eccrine sweat glands (9400).

Correspondence: Toshiyuki Yamamoto, M.D., Ph.D., Department of Dermatology, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1295, Japan. Email: [email protected]

© 2014 Japanese Dermatological Association

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Disseminated nodular and granulomatous secondary syphilis.

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