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Jankowska L, Adamski Z, Polańska A, Bowszyc-Dmochowska M, Plagens-Rotman K, Merks P, Czarnecka-Operacz M, Żaba R. Challenges in the Diagnosis of Tertiary Syphilis: Case Report with Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16992. [PMID: 36554872 PMCID: PMC9778711 DOI: 10.3390/ijerph192416992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
Tertiary syphilis is a large diagnostic challenge. It is rarely the case that it affects the skin, bone tissue and the eyes at the same time. The presented case shows that extensive symptomatology of syphilis poses a challenge in making a proper diagnosis in patients whose history does not suspect STDs. The study aims to present the case of a young woman hospitalized with a suspected autoimmune disease, diagnosed with symptomatic late syphilis with involvement of the skin, bones and eyes.
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Affiliation(s)
- Lucyna Jankowska
- Department of Dermatology, Heliodor Święcicki Clinical Hospital, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Zygmunt Adamski
- Department of Dermatology, Heliodor Święcicki Clinical Hospital, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Adriana Polańska
- Department of Dermatology and Venenerology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Monika Bowszyc-Dmochowska
- Department of Dermatology, Heliodor Święcicki Clinical Hospital, Poznan University of Medical Sciences, 60-806 Poznan, Poland
| | - Katarzyna Plagens-Rotman
- Center for Pediatric, Adolescent Gynecology and Sexology Division of Gynecology, Department of Perinatology and Gynecology, Poznan University of Medical Sciences, 61-758 Poznan, Poland
| | - Piotr Merks
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Collegium Medicum, Cardinal Stefan Wyszynski University in Warsaw, 01-938 Warszawa, Poland
| | - Magdalena Czarnecka-Operacz
- Allergic and Occupational Skin Diseases Unit, Department of Dermatology, Medical University of Poznań, 60-355 Poznan, Poland
| | - Ryszard Żaba
- Department of Dermatology and Venenerology, Poznan University of Medical Sciences, 60-806 Poznan, Poland
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2
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Phan K, Gorji M, Smith SD, Harvey R. Granulomatous secondary syphilis: uncommon and atypical presentation. Int J Dermatol 2020; 59:e270-e272. [PMID: 32403154 DOI: 10.1111/ijd.14936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/27/2020] [Accepted: 04/18/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin Phan
- Department of Dermatology, Liverpool Hospital, Sydney, NSW, Australia
| | - Maddie Gorji
- Douglass Hanly Moir Pathology, in Partnership with the Skin Hospital, Darlinghurst, Sydney, NSW, Australia
| | - Saxon D Smith
- The Dermatology And Skin Centre, Gosford, NSW, Australia
| | - Rhonda Harvey
- Green Square Dermatology, Waterloo, Sydney, NSW, Australia
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3
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Forrestel AK, Kovarik CL, Katz KA. Sexually acquired syphilis: Historical aspects, microbiology, epidemiology, and clinical manifestations. J Am Acad Dermatol 2019; 82:1-14. [PMID: 30986477 DOI: 10.1016/j.jaad.2019.02.073] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 02/10/2019] [Accepted: 02/12/2019] [Indexed: 01/03/2023]
Abstract
Syphilis is caused by infection with the spirochetal bacterium Treponema pallidum subsp. pallidum. It was first recognized in the late 15th century. Since 2000, the incidence of sexually acquired syphilis has increased substantially in the developed world, with men who have sex with men and persons living with HIV infection disproportionately affected. Clinical manifestations of syphilis are protean and often include mucocutaneous manifestations. The first article in this continuing medical education series reviews historical aspects, microbiology, epidemiology, and clinical manifestations of sexually acquired syphilis.
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Affiliation(s)
- Amy K Forrestel
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Carrie L Kovarik
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kenneth A Katz
- Department of Dermatology, Kaiser Permanente, San Francisco, California
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4
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Santosa A, Wong CF, Koh LW. Multisystemic sarcoidosis-important lessons learnt from one of the great imitators. BMJ Case Rep 2019; 12:e227929. [PMID: 30904884 PMCID: PMC6453389 DOI: 10.1136/bcr-2018-227929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2019] [Indexed: 12/29/2022] Open
Abstract
We report a case of a woman who was admitted with a suspicion of metastatic malignancy of unknown primary origin. A few months prior to her admission, she presented to a rheumatologist with acute anterior uveitis, psoriasiform rashes and polyarthritis. A diagnosis of psoriatic arthropathy was made and she was treated accordingly. Soon after she presented with persistent back and right upper quadrant abdominal pain for which she had a CT scan done with evidence of hilar lymphadenopathy, liver hypodensities and lytic-sclerotic bone lesions. She was referred to our hospital for further investigations and management. After re-exploring her clinical presentation and further investigations (including a liver biopsy), a diagnosis of multisystemic sarcoidosis with ocular, reticuloendothelial, hepatic and skeletal involvement was made. The patient was started on systemic glucocorticoids and second line immunosuppressants and demonstrated significant clinical improvement with resolution of her liver granulomata on imaging and improvement in her back pain. The case illustrates the importance of a thorough clinical assessment, review of investigations and an open mind in the evaluation of a patient.
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Affiliation(s)
- Anindita Santosa
- Medicine (Rheumatology), Changi General Hospital, Singapore, Singapore, Singapore
| | | | - Li Wearn Koh
- Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore, Singapore
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5
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Bittencourt MDJS, Brito ACD, Nascimento BAM, Carvalho AH, Drago MG. Nodular tertiary syphilis in an immunocompetent patient. An Bras Dermatol 2017; 91:528-30. [PMID: 27579755 PMCID: PMC4999118 DOI: 10.1590/abd1806-4841.20163837] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 01/09/2015] [Indexed: 11/25/2022] Open
Abstract
Acquired syphilis can be divided into primary, secondary, latent, and tertiary
stages. About 25% of patients with untreated primary syphilis will develop late
signs that generally occur after three to five years, with involvement of
several organs. The authors present an immunocompetent female who developed a
tertiary stage syphilis presenting with long-standing nodular plaques.
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6
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Mitteldorf C, Tronnier M. Histologic features of granulomatous skin diseases. J Dtsch Dermatol Ges 2016; 14:378-88. [PMID: 27027748 DOI: 10.1111/ddg.12955] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Granulomatous disorders affecting the skin belong to a heterogeneous group of diseases, which were predominantly classified based on pathogenetic features. In infections diseases a granuloma is formed if an agent could not be eliminated by the immune system. Typical agents which cause granulomatous reactions are mycobacteria, fungal infections, especially extra European agent, which could effect the skin by, dissemination (e.g. histoplasmosis) or parasites, like leishmaniasis.
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Affiliation(s)
- Christina Mitteldorf
- Department of Dermatology, Venereology, and Allergology, HELIOS Hospital, Hildesheim, Germany
| | - Michael Tronnier
- Department of Dermatology, Venereology, and Allergology, HELIOS Hospital, Hildesheim, Germany
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7
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Boyd AS. Syphilitic gumma arising in association with foreign material. J Cutan Pathol 2016; 43:1028-1030. [DOI: 10.1111/cup.12770] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 10/21/2015] [Accepted: 07/12/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Alan S. Boyd
- Department of Medicine, Division of Dermatology and Pathology; Vanderbilt University; Nashville TN USA
- Department of Pathology; Vanderbilt University; Nashville TN USA
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8
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Mitteldorf C, Tronnier M. Histologische Merkmale granulomatöser Hauterkrankungen: Teil 2: Infektiöse granulomatöse Erkrankungen. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.12955_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Christina Mitteldorf
- Klinik für Dermatologie, Venerologie und Allergologie; HELIOS Klinikum; Hildesheim
| | - Michael Tronnier
- Klinik für Dermatologie, Venerologie und Allergologie; HELIOS Klinikum; Hildesheim
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Jorge LMA, da Costa Nery JA, Bernardes Filho F. Tertiary syphilis: tubero-serpiginous and tubero-ulcerous syphilids. Braz J Infect Dis 2016; 20:308-9. [PMID: 27026572 PMCID: PMC9425366 DOI: 10.1016/j.bjid.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/19/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
| | | | - Fred Bernardes Filho
- Dermatology Division, Department of Medical Clinics, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
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Krasnoselskikh TV, Mikheev GN, Grigorian AE, Yastrebov VV, Sokolovskiy EV. A case of tertiary syphilis manifested with multiple skin gummas. VESTNIK DERMATOLOGII I VENEROLOGII 2015. [DOI: 10.25208/0042-4609-2015-91-2-84-93] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The tertiary cutaneous syphilis has become extremely rare as a result of the effective treatment of early syphilis with penicillin and occasional antibiotic therapy for concomitant infections. We report a case of tertiary gummatous syphilis associated with asymptomatic neurosyphilis that was initially misdiagnosed as basal cell carcinoma of the skin. A 67-year-old woman presented with the 18-month history of multiple, firm, bluish-red asymptomatic nodes on the parietal scalp, chin and lateral part of the trunk that had developed without preceding trauma. One node on the trunk had small central ulceration covered with dry yellowish crust. On the left retroauricular area the brownish-purple atrophic scar was observed. Blood tests revealed reactive VDRL, ELISA and TPHA assays. Skin biopsy has showed endarteritis with endothelial swelling and caseating granulomas along with plasmocytic infiltrate in the dermis and subcutaneous tissue. Increased lymphocyte count and the positive VDRL test with cerebrospinal fluid have confirmed the diagnosis of asymptomatic syphilitic meningitis in this patient. The treatment with aqueous penicillin intravenously has lead to resolution of the skin infiltrates and progressive more than 4-fold reduction of follow-up serum VDRL titers. This case is reported as a reminder of the possibility of tertiary syphilis with misleading clinical patterns in patients infected during the epidemics of 1995-2000. We would like to emphasize the necessity to perform timely serological and pathomorphological study to prevent misdiagnosis and mistreatment.
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Xu XG, Li YH, Gao XH, Chen HD, Zhang YQ. A case of tertiary neurosyphilis presenting with moth-eaten bone lesions. Dermatol Ther 2014; 26:486-8. [PMID: 24552413 DOI: 10.1111/dth.12020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Syphilis, the "great imitator," with regard to skin diseases, is a chronic systemic infectious disease with a clinical course that waxes and wanes. The incidence of tertiary syphilis had decreased drastically these decades. We report a case of tertiary neurosyphilis presenting with moth-eaten bone lesions of the lower extremities. To the best of our knowledge, we have not seen such reports.
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Affiliation(s)
- Xue-Gang Xu
- Department of Dermatology, The Second Hospital of Jilin University, Changchun, China; Department of Dermatology, No.1 Hospital of China Medical University, Shenyang, China
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12
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Radojevic N, Vukmirovic F, Curovic I, Soc M. Asymptomatic syphilitic massive necrosis of the spleen in late syphilis. Int J STD AIDS 2013; 24:912-5. [PMID: 23970621 DOI: 10.1177/0956462413490145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The varieties of luetic clinical variants are countless in nature. In this regard, an autopsy case of a 72-year-old homeless man who accidentally succumbed to carbon-monoxide poisoning is here presented and reviewed. The autopsy revealed the highly unusual finding of asymptomatic syphilitic necrosis of spleen followed by luetic mesaortitis, a solitary skin gumma, and syphilitic arthritis. The spleen was 8×4×3 cm in size; the capsule was completely calcified and firm, 3 to 5 mm thick. Only in the region of the hilus was a small part of preserved tissue found. After puncturing the capsule, a brown-yellowish pus-like mass was found which filled the entire space inside. When reviewing the relevant literature, this case and its finding of pan splenic necrosis accompanied by a calcified capsule seem to be unique in nature. In terms of the final diagnosis, a Treponema pallidum haemagglutination assay confirmed it to be syphilis. Since it was a late stage of the disease, it is estimated that it may have been present for more than 20 or 30 years in the deceased.
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Affiliation(s)
- Nemanja Radojevic
- Department of Forensic Medicine, Clinical Centre of Montenegro, Faculty of Medicine, University of Montenegro, Podgorica, Montenegro
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13
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The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol 2011; 33:433-60. [PMID: 21694502 DOI: 10.1097/dad.0b013e3181e8b587] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Syphilis has plagued mankind for centuries and is currently resurgent in the Western hemisphere. Although there has been a significant reduction of tertiary disease and recognition of facilitative interactions with human immunodeficiency virus infection, the natural history of syphilis has remained largely unchanged; thus, new strategies are required to more effectively combat this pathogen. The immunopathologic features of experimental syphilis in the rabbit; the course, stages, and pathology of human syphilis; and a comparison of human syphilis with leprosy suggest that the clinical course of syphilis and its tissue manifestations are determined by the balance between delayed-type hypersensitivity (DTH) and humoral immunity to the causative agent, Treponema pallidum. A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease. Many of the protean symptoms/appearances of secondary and tertiary human syphilis are manifestations of immune reactions that fail to clear the organism, due to a lack of recruitment and, more importantly, activation of macrophages by sensitized CD4 T cells. The Bacillus Calmette-Guerin vaccination can enhance DTH and has been shown to produce a low, but measurable, beneficial effect in the prevention of leprosy, a disease that shows a disease spectrum with characteristics in common with syphilis. In the prevention of syphilis, a potential vaccine protective against syphilis should be designed to augment the DTH response.
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14
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Affiliation(s)
- Teresa M Pereira
- Department of Dermatology and Venereology, Hospital de São Marcos, Braga, Portugal.
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15
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Abstract
The evaluation of patients with subcutaneous nodules remains a diagnostic challenge. The presence of nodules can be a clue to an underlying systemic disease; however, the varied presentations of nodules and numerous disease associations make the assessment of patients with nodules far from simple. With further investigation into the appearance, location, and symptoms associated with nodules, the clinical significance of these lesions can become clearer and aid in logical diagnostic evaluation. We have reviewed the causes of nodules with emphasis on those associated with rheumatic disease and provide guidelines for nodule evaluation to better characterize disease association and lead to directed diagnostic assessment.
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16
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Syphilis. Dermatopathology (Basel) 2006. [DOI: 10.1007/3-540-30244-1_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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17
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Cather JC, Cather JC. Diverse manifestations associated with a single dermatosis. Proc (Bayl Univ Med Cent) 2005; 16:349-51. [PMID: 16278710 PMCID: PMC1200793 DOI: 10.1080/08998280.2003.11927926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Jennifer Clay Cather
- Division of Dermatology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas, USA
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Abstract
The clinical manifestations of syphilis are variable in appearance and have been described for centuries. The disease has been arbitrarily divided mainly into three stages. Uncommon presentations of syphilis in adults include (a) primary syphilis-atypical forms of chancre vary in size, shape, morphology, and color. Small ulcus durum is single or multiple, grouped, or herpetiform. Giant necrotic and phagedenic chancres are resolved with scar formation. In intratriginous areas, ulcus durum is rhagadiform, linear, "rocket type," or bilateral. (b) Secondary syphilids include macular (roseolas, leukomelanoderma), papular (small miliar or lichenoid, or with large size-lenticular or nummular), papulosquamous, syphilis cornee, psoriasiform, annular en cockade, nodular, condylomata lata, malignant syphilis, and others; there are also mucosal lesions, loss of the hairs, and alteration of the nails. (c) Tertiary syphilis occurs decades after infection in three main forms: gummatous, cardiovascular, and neurosyphilis (asymptomatic, meningeal, meningovascular, and parenchymatous-such as general paresis or tabes dorsalis). Early recognition of the clinical manifestations of syphilis is important for the start of treatment, recovery of patients, and the prevention of the spread of disease.
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Autier J, Valeyrie-Allanore L, Picard-Dahan C, Lepilliez C, Marinho E, Petit T, Crickx B. [Widespread chronic purple plaques]. Ann Dermatol Venereol 2005; 132:569-70. [PMID: 16142108 DOI: 10.1016/s0151-9638(05)79344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- J Autier
- Service de Dermatologie, Hôpital Bichat, AP-HP, Paris
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Treudler R, Knoll B, Ackermann-Simon J, Roesler B, Krahl D, Orfanos CE. Therapie resistente anuläre Hautveränderungen. Hautarzt 2005; 56:480-2. [PMID: 15599689 DOI: 10.1007/s00105-004-0853-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- R Treudler
- Klinik und Hochschulambulanz für Dermatologie, Charité-Campus Benjamin Franklin, Berlin.
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21
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Rocha N, Horta M, Sanches M, Lima O, Massa A. Syphilitic gumma - cutaneous tertiary syphilis. J Eur Acad Dermatol Venereol 2004; 18:517-8. [PMID: 15196182 DOI: 10.1111/j.1468-3083.2004.00960.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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