Nodular secondary syphilis with associated granulomatous inflammation: case report and literature review

Usefulness of polymerase chain reaction analysis in a case of clinically and histologically atypical nodular granulomatous secondary syphilis

We report a case of a nodular granulomatous secondary syphilis histologically resembling tuberculids in a patient with positive quantiferon test and serology for syphilis. Polymerase chain reaction (PCR) analysis led to the diagnosis. We underline the usefulness of PCR in clinically and histologically doubtful cases in order to avoid misdiagnosis and delay treatment.

Granulomatous Secondary Syphilis: A Case Report with a Brief Overview of the Diagnostic Role of Immunohistochemistry

The diagnosis of syphilis can be challenging for dermatologists and dermatopathologists. In particular, secondary syphilis can have different clinical and histopathological presentations. A granulomatous tissue response is an unusual finding in secondary syphilis. We report the case of a 77-year-old man who presented with a 4-week history of non-pruritic generalised macules, papules, nodules and plaques. Histopathologically, there was a dense perivascular and periadnexal lympho-histiocytic dermal infiltrate with non-palisading and non-caseifying epithelioid granulomas and abundant plasma cells. The diagnosis of syphilis was confirmed by serology and immunohistochemical detection of Treponema pallidum in the biopsy specimen. A brief overview of the diagnostic role of immunohistochemistry is also provided, with particular emphasis on reported cases of granulomatous secondary syphilis.

Condyloma lata mimicking vulvar carcinoma in an immunocompromised patient: A case report

Background

Syphilis is a sexually transmitted infection with increasing incidence in the United States. Presentations of syphilis vary widely and can be easily mistaken for other diagnoses, including cancer, especially in atypical cases.

Case description

At her delivery after no prenatal care, a 35-year-old woman was found to have exophytic vulvar and perianal lesions, inguinal lymphadenopathy, and a new diagnosis of HIV, with a strong clinical concern for vulvar and/or anal carcinoma. She was subsequently diagnosed with presumed late latent syphilis and began weekly intramuscular penicillin G benzathine treatment. CT imaging demonstrated a perineal plaque-like area with bilateral inguinal, external iliac and retroperitoneal lymphadenopathy. She was seen in gynecologic oncology clinic one week after her initial presentation with notable improvement in the vulvar lesions, raising suspicion for condyloma lata rather than invasive or preinvasive disease on the vulva, however concern remained for dysplasia in the perianal lesion. Another week later, she underwent an exam under anesthesia with vulvar and perianal biopsies revealing chronic inflammation and granulomatous change without evidence of malignancy or dysplasia. At the four week post operative visit, there was almost complete resolution of the lesions.

Conclusion

Syphilis should be considered in the differential diagnosis of atypical vulvar lesions.

Granulomatous secondary syphilis: Another diagnostic pitfall for the dermatopathologist

Syphilis is growing ever more prevalent in the United States with its incidence rising every year. Dermatopathologists need to maintain a high index of suspicion to avoid delayed diagnosis of this treatable disease. Accordingly, it is imperative to be aware of its myriad of presentations-including secondary syphilis with granulomatous inflammation. Most cases show aggregations of epithelioid histiocytes associated with plasma cells. Other patterns include an interstitial granuloma-annulare-like pattern, sarcoidal, and tuberculoid pattern. Immunohistochemical stains for Treponema pallidum may be negative, especially in late secondary or tertiary syphilis. We present a case of nodular secondary syphilis with granulomatous inflammation with negative T. pallidum staining.

Secondary Syphilis With Elastophagocytosis: An Unusual Histologic Finding

ABSTRACT

Elastophagocytosis is a characteristic finding of granulomatous and elastolytic disorders. It is defined by phagocytosed elastic fibers within histiocytes, multinucleated giant cells, or both. This finding has also been associated with certain medications, malignancies, inflammatory conditions, and infectious disorders. Although Drs Ragaz and Ackerman reported elastophagocytosis in a secondary syphilis lesion in a review of actinic granuloma in 1979, more recent publications have not recognized this finding. We present a case of elastophagocytosis within a lesion of secondary syphilis in a 65-year-old man. Biopsy from his left forearm demonstrated features of secondary syphilis including subtle vacuolar alteration with mild superficial and mid perivascular lymphoplasmacytic inflammation. There were interstitial giant cells with phagocytosed elastic fibers within the superficial dermis. Spirochete immunostain was positive with confirmatory Treponema pallidum IgG antibody and RPR titer. In this report, we present a unique case of secondary syphilis.

[New aspects in the histopathology of infectious skin diseases]

BACKGROUND

An infectious pathogenesis should always be considered in inflammatory infiltrates in the skin. While some organisms can be recognized on hematoxylin-eosin staining (e.g. yeasts, leishmania), histochemical and immunohistochemical stainings are available for others.

OBJECTIVES

If no organisms are seen in a section, the diagnosis of an infection cannot be made with surety, but the pattern of the inflammatory infiltrate can still be suggestive of an infectious process. New or little-known reaction patterns and difficulties in differential diagnosis will be demonstrated.

MATERIALS AND METHODS

Selective literature review and analysis of individual cases.

RESULTS

Studies using molecular techniques to identify organisms in biopsy specimens have helped to better characterize the histomorphological spectrum of skin infiltrates in infectious skin diseases. Apart from unusual herpes simplex and varicella zoster infections, the histopathology of coxsackie virus and measles exanthem, borreliosis, syphilis, and of cutaneous leishmaniasis is demonstrated. For numerous organisms, molecular tests have been established that can be used on the formalin-fixed, paraffin-embedded material.

CONCLUSIONS

Selected skin infections demonstrate the broad histomorphological spectrum of skin infiltrates induced by infectious organisms. It is important for histopathologists to know which reaction pattern requires them to alert the clinician to necessary ancillary diagnostics (culture, serology) and when to consider molecular diagnostics to be performed on the biopsy specimen.

[Relevance of biopsies for the diagnostics of infectious skin diseases]

Pathogen-related skin infections are a common problem in the dermatological practice. Apart from culturing and serological detection methods, a skin biopsy is a possible diagnostic procedure, especially when the clinical picture is unspecific and other non-infectious skin diseases are considered as possible differential diagnoses. Some organisms can already be detected by routine staining methods (hematoxylin & eosin, e. g., yeasts, Leishmania), for others numerous histochemical and immunohistochemical stains are available, e. g. periodic acid-Schiff reaction (PAS) and Grocott for hyphae and spores, Ziehl-Neelson and Fite-Faraco for Mycobacteria or specific antibodies for Treponema pallidum or herpesviruses. In other instances, an infectious disease may not be diagnosed with certainty in a histological section but the pattern of inflammatory infiltrates is highly suggestive of an infectious cause. Based on such reaction patterns, the dermatopathologist can advise the clinician to perform cultures or serological investigations or additional molecular biological techniques can be applied to the biopsy specimen in order to identify the pathogens. This article presents skin infections with their histopathological features and highlights diseases that can be diagnosed with certainty in a biopsy and those in which a biopsy is helpful to exclude differential diagnoses or to perform molecular diagnostics on the specimen.

Sexually acquired syphilis: Historical aspects, microbiology, epidemiology, and clinical manifestations

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.

Inflammatory Dermatopathology for General Surgical Pathologists

Owing to the wide variety and complexity of inflammatory skin diseases, inflammatory dermatopathology can be a challenging topic for dermatopathologists and general surgical pathologists alike. Following a basic tissue reaction pattern approach, this article reviews the most common and important entities of each pattern, with emphasis on differential diagnosis, diagnostic pitfalls, and appropriate workup when indicated. A few dermatologic emergencies are also discussed.

IFNγ Enhances CD64-Potentiated Phagocytosis of Treponema pallidum Opsonized with Human Syphilitic Serum by Human Macrophages

Syphilis is a multi-stage, sexually transmitted disease caused by the spirochete Treponema pallidum (Tp). Considered broadly, syphilis can be conceptualized as a dualistic process in which spirochete-driven inflammation, the cause of clinical manifestations, coexists to varying extents with bacterial persistence. Inflammation is elicited in the tissues, along with the persistence of spirochetes to keep driving a robust immune response while evading host defenses; this duality is best exemplified during the florid, disseminated stage called secondary syphilis (SS). SS lesions typically contain copious amounts of spirochetes along with a mixed cellular infiltrate consisting of CD4⁺ T cells, CD8⁺ T cells, NK cells, plasma cells, and macrophages. In the rabbit model, Tp are cleared by macrophages via antibody-mediated opsonophagocytosis. Previously, we demonstrated that human syphilitic serum (HSS) promotes efficient uptake of Tp by human monocytes and that opsonophagocytosis of Tp markedly enhances cytokine production. Herein, we used monocyte-derived macrophages to study Tp–macrophage interactions ex vivo. In the absence of HSS, monocyte-derived macrophages internalized low numbers of Tp and secreted little cytokine (e.g., TNF). By contrast, these same macrophages internalized large numbers of unopsonized Borrelia burgdorferi and secreted robust levels of cytokines. Maturation of macrophages with M-CSF and IFNγ resulted in a macrophage phenotype with increased expression of HLA-DR, CD14, inducible nitric oxide synthase, TLR2, TLR8, and the Fcγ receptors (FcγR) CD64 and CD16, even in the absence of LPS. Importantly, IFNγ-polarized macrophages resulted in a statistically significant increase in opsonophagocytosis of Tp accompanied by enhanced production of cytokines, macrophage activation markers (CD40, CD80), TLRs (TLR2, TLR7, TLR8), chemokines (CCL19, CXCL10, CXCL11), and T_H1-promoting cytokines (IL-12, IL-15). Finally, the blockade of FcγRs, primarily CD64, significantly diminished spirochetal uptake and proinflammatory cytokine secretion by IFNγ-stimulated macrophages. Our ex vivo studies demonstrate the importance of CD64-potentiated uptake of opsonized Tp and suggest that IFNγ-activated macrophages have an important role in the context of early syphilis. Our study results also provide an ex vivo surrogate system for use in future syphilis vaccine studies.

Secondary syphilis primarily presenting with multiple nodules on the scalp: Case report and published work review

Syphilis, a sexually transmitted disease caused by Treponema pallidum, manifests with a broad spectrum of clinical presentations that usually involves skin. Nodular secondary syphilis occurs rarely, and mostly manifests as disseminated papulonodules or plaques over the trunk and limbs. We report an extremely rare case of nodular secondary syphilis that primarily presented with multiple nodules on the scalp, resembling Rosai-Dorfman disease or cutaneous malignant metastasis. Immunohistochemistry confirmed T. pallidum spirochetes microscopically.

Papulonodular Secondary Syphilis Presenting as Multiple Distinct Cutaneous Lesions in an HIV-Positive Transgender Woman

We present the first reported case of papulonodular secondary syphilis in an HIV-positive transgender female. Syphilis is classified into primary, secondary, latent, and tertiary stages, with secondary syphilis having notably diverse cutaneous manifestations. Our patient presented with diverse lesions throughout her body, all pathologically consistent with papulonodular secondary syphilis. Proper identification of the multiple presentations of syphilis is crucial to early diagnosis and treatment. This report seeks to broaden the scope of dermatological manifestations that arise secondary to papulonodular syphilis in HIV-positive patients.

Eosinophil-rich syphilis: a report of four cases

The differential diagnosis for eosinophil-rich skin lesions often includes a drug reaction, allergic contact dermatitis and rarely, response to a helminth infection. However, many unrelated entities, such as infections, neoplasms and inflammatory dermatoses, can have a prominent eosinophilic infiltrate. Syphilis is classically associated with plasma cells, but other patterns of inflammation have been reported, including ulcerative, granulomatous and eosinophil-rich. Classic teaching might indicate that the presence of eosinophils argues against a diagnosis of syphilis. We present four cases of secondary syphilis with increased eosinophils, ranging from 8 to >200 eosinophils per 10 high-power fields (×400 magnification). Patient 1 had lesions on the penis and scrotum, with greater than 200 eosinophils per 10 high-power fields. Patient 2 had lesions on the back, with 150 eosinophils per 10 high-power fields. Patient 3 had lesions on the bilateral arms, with 8 eosinophils per 10 high-power fields. Patient 4 had lesions involving the anus, with 17 eosinophils per 10 high-power fields. These cases highlight that the presence of an eosinophil-rich infiltrate on skin biopsy should not exclude syphilis from the differential diagnosis.