Tertiary syphilis: tubero-serpiginous and tubero-ulcerous syphilids

Lívia Montelo Araújo Jorge José Augusto da Costa Nery Fred Bernardes Filho About the authors

A 50-year-old heterosexual, HIV seronegative, male patient presented at the Dermatology Service with asymptomatic erythematous lesions on his left elbow and forehead for four months. He denied previous treatment, comorbidities and had no systemic symptoms. The dermatological examination showed erythematous purplish tuberous circinate plaque on his forehead (Fig. 1A), reddish purplish tubers, some ulcerated on the left elbow (Fig. 1B), and bulky lymphadenopathy in the neck (Fig. 1C); absence of mucosal lesions; preserved skin sensitivity and peripheral nerves without changes. Test results: VDRL 1/64, TPHA reagent, and anti-HIV nonreactive. The diagnosis of tertiary syphilis was established and treatment with penicillin benzathine 7,200,000 IU in three weekly intramuscular doses of 2,400,000 IU was administered. Reduction of the lesion was observed one week thereafter and clinical cure was achieved after the end of treatment (Fig. 2).

Fig. 1
Tubero-serpiginous syphilids on forehead (A), tubero-ulcerous syphilids on left elbow (B) and bulky lymphadenopathy in the neck (C).

Fig. 2
The disappearance of tubero-serpiginous syphilids on forehead after the end of treatment.

Syphilis is a millenarian disease but still remains rather prevalent, especially in some high-risk behavior individuals.1,1 Bernardes Filho F, Santos MVPQ, Cariello LBA, et al. Syphilis in presentation with overlapping phases: how to lead? DST – J Bras Doenças Sex Transm. 2012;24:109–12. 22 Fernandes FR, Zanini PB, Rezende GR, et al. Syphilis infection, sexual practices and bisexual behaviour among men who have sex with men and transgender women: a cross-sectional study. Sex Transm Infect. 2015;91:142–9. In contrast to the increasing incidence of early syphilis (primary and secondary), cases of classic late syphilis (tertiary) as a result of untreated syphilis are rarely seen.3,3 Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006;81:111–26. 44 Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79. Approximately half of patients with tertiary syphilis presents “benign” late syphilis with gums emergence.4,4 Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79. 55 Wu SJ, Nguyen EQ, Nielsen TA, Pellegrini AE. Nodular tertiary syphilis mimicking granuloma annulare. J Am Acad Dermatol. 2000;42:378–80. Around a quarter develop cardiovascular manifestations and another quarter develop neurological symptoms.4,4 Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79. 66 Revathi TN, Bhat S, Asha GS. Benign nodular tertiary syphilis: a rare presenting manifestation of HIV infection. Dermatol Online J. 2011;17:5. Gums are locally destructive lesions in the skin, liver, bones, and other organs.4,4 Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79. 77 Rocha N, Horta M, Sanches M, Lima O, Massa A. Syphilitic gumma—cutaneous tertiary syphilis. J Eur Acad Dermatol Venereol. 2004;18:517–8. Skin gums are nodular or nodular ulcerative lesions, with an arciform pattern.3,3 Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006;81:111–26. 44 Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79.

Conflicts of interest

The authors declare no conflicts of interest.

References

  • 1
    Bernardes Filho F, Santos MVPQ, Cariello LBA, et al. Syphilis in presentation with overlapping phases: how to lead? DST – J Bras Doenças Sex Transm. 2012;24:109–12.
  • 2
    Fernandes FR, Zanini PB, Rezende GR, et al. Syphilis infection, sexual practices and bisexual behaviour among men who have sex with men and transgender women: a cross-sectional study. Sex Transm Infect. 2015;91:142–9.
  • 3
    Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006;81:111–26.
  • 4
    Stary A, Stary G. Infecções Sexualmente Transmissíveis (Sífilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367–79.
  • 5
    Wu SJ, Nguyen EQ, Nielsen TA, Pellegrini AE. Nodular tertiary syphilis mimicking granuloma annulare. J Am Acad Dermatol. 2000;42:378–80.
  • 6
    Revathi TN, Bhat S, Asha GS. Benign nodular tertiary syphilis: a rare presenting manifestation of HIV infection. Dermatol Online J. 2011;17:5.
  • 7
    Rocha N, Horta M, Sanches M, Lima O, Massa A. Syphilitic gumma—cutaneous tertiary syphilis. J Eur Acad Dermatol Venereol. 2004;18:517–8.

Publication Dates

  • Publication in this collection
    May-Jun 2016

History

  • Received
    16 Jan 2016
  • Accepted
    19 Jan 2016
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