Dermatol Sinica, Sep 2005 172

Multiple Erythematous Nodular Eruptions in a 32-year-old Man

Po-Hsuan Lu Yang-Chih Lin Yu-Hung Wu

CASE REPORTA 32-year-old single male came to us with asymptomatic nodular skin lesions on his trunk, inner

arms, and legs. He lived near a pet store. The lesions had been present for two months. They initiallyappeared on the trunk and gradually spread to involve the limbs. Cutaneous examination revealed dis-crete erythematous papules and nodules on the abdomen (Fig. 1A), lower back (Fig. 1B), and limbsbilaterally but asymmetrically. The lesions were not tender, and they spared the mucous membranes,palms, and soles. The physical examination was otherwise normal. The white blood cell count was6300/mm3 with 81% neutrophils (normal range 55-75%). A skin biopsy specimen was obtained fromhis abdomen (Fig. 2A, 2B).

From the Department of Dermatology, Mackay Memorial HospitalAccepted for publication: March 31, 2005Reprint requests: Yang-Chih Lin, M.D., Department of Dermatology, Mackay Memorial Hospital No.92, Sec2, Chung-Shan N Rd.,10449, Taipei, TaiwanTEL: 886-2-2543-3535 ext.2556 FAX: 886-2-25433642

Fig. 2 A (H & E, 200X), B (H & E, 400X)

Resident Forum

Fig. 1Discrete, erythematous papules and nodules on the abdomen(A)and erythematous nodules on the lower back(B).

A

B

A B

173 Dermatol Sinica, September 2005

Diagnosis: Nodular Secondary Syphilis

Microscopic Findings and Clinical CourseTissue from a biopsy of a nodular lesion

on the abdomen showed a wedge-shape dermalinfiltrate of lymphocytes, plasma cells, histio-cytes and occasional multinucleated giant cells.CD3 (+) T and CD20 (+) B cells in nearly equalproportions were distributed throughout theinfiltrate. Most of the histiocytes and giant cellswere CD68 (+). Stains for fungi (periodic acid-Schiff stain), mycobacteria (acid fast stain),leishmania (Giemsa stain) and spirochetes(Warthin-Starry silver stain) were all negative.The overall findings were consistent with amononuclear-cell granulomatous dermatitis,secondary either to an infectious process or alymphoproliferative disorder. A rapid plasmareagin test was reactive at a titer of 1:8, and theconfirmatory Treponema pallidum hemaggluti-nation test was positive at a titer of 1:640. A testfor human immunodeficiency virus antibodywas negative.

On further questioning, the patient admit-ted having had sexual intercourse four monthsearlier. He couldn t recall any genital lesions.He was given 2.4 million units of benzathinepenicillin by intramuscular injection. One weeklater, all of his nodular lesions had regressed,leaving some reddish macules. Based on thehistory, serology and the rapid response to peni-cillin, the final diagnosis was nodular secondarysyphilis.

DISCUSSIONThe cutaneous lesions of secondary

syphilis are diverse, while the most being macu-lar, maculopapular, papulosquamous, and annu-lar. Nodular and pustular eruptions seldomoccur.1 Since 1980, 12 cases of nodular second-ary syphilis have been reported in the Englishliterature.2-7 Most patients were male. The age ofonset ranged from 22 to 66. The reported distri-bution of the nodules varied from diffuse tolocalized, and three of the patients had mucosalinvolvement. Over half have presented withlymphadenopathy. In addition to the nodular

lesions, some patients also had papules or annu-lar plaques, and some patients experienced pru-ritus. The response to treatment was the same asin more typical secondary syphilis.

One quarter of reported patients with sec-ondary syphilis did not recall a chancre and themajority of patients have only had skin lesions.1

Even after repeated questioning, our patientcould not recall any genital lesions, and hedenied other constitutional symptoms except formild malaise prior the eruption.

The histopathologic appearance of second-ary syphilis is variable. The reported histologi-cal patterns in nodular secondary syphilis aremainly diffuse dermal infiltrates and a granulo-matous inflammation.2-7 Granulomas mayresemble epithelioid, sarcoid or tubercle lesions.

Nodular lesions are rare in secondarysyphilis. However, it is imperative to diagnosesyphilis in the secondary stage when it respondsrapidly to treatment, rather than risk the possi-ble progression to tertiary disease. Secondarysyphilis should therefore be considered in thedifferential diagnosis of nodular skin lesions. Ahigh index of suspicion and a careful sexual his-tory, followed by serological tests, should leadto accurate diagnosis and prompt treatment.

REFERENCES1. Sanchez MR: Syphilis. In: Fitzpatrick TB, Eisen

AZ, Wolff K, et al., eds. Dermatology in GeneralMedicine. 6th ed. New York: McGraw-Hill, 2551-2581, 2003.

2. Dave S, Gopinath DV, Thappa DM: Nodular sec-ondary syphilis. Dermatol Online J 9: 9, 2003.

3. Papini M, Bettacchi A, Guiducci A: Nodular sec-ondary syphilis. Br J Dermatol 138: 704-705, 1998.

4. Adriaans B: An erythematous nodular eruption.Secondary syphilis. Arch Dermatol 128: 978-979,1992.

5. Cohen PR, Hymes SR: Secondary syphilis presentingas cutaneous nodules in a patient previously treatedfor laryngeal carcinoma. Cutis 49: 51-54, 1992.

6. Hodak E, David M, Rothem A, et al.: Nodularsecondary syphilis mimicking cutaneous lym-phoreticular process. J Am Acad Dermatol 17:914-917, 1987.

7. Sapra S, Weatherhead L: Extensive nodular second-ary syphilis. Arch Dermatol. 125: 1666-1669, 1989.