Case of Circinate Syphilitic Lesions reported in NEJM

Dr Suruthi Purushothaman and Dr Bhargavi Mayakuntla at Rangaraya Medical College, Kakinada, India have reported a rare case of Circinate syphilitic lesion which has been published in the New England journal of Medicine.

Secondary syphilis should be considered in the differential diagnosis of virtually any skin rash of unknown etiology.

The classic finding of secondary syphilis is a lacy, erythematous, maculopapular rash covering the trunk and abdomen. Palmar or plantar lesions, if present, are particularly suggestive of the diagnosis.

The skin eruption is usually nonpruritic, but some patients complain of itching and present with excoriated lesions. Secondary syphilis must be considered in the differential diagnosis of any generalized skin eruption, particularly in MSM and pregnant women. The differential diagnosis for the rash of secondary syphilis includes viral exanthema, drug eruption, and primary HIV infection, among other etiologies. If untreated, approximately 25% of patients with secondary syphilis will have a relapse of active secondary syphilis, typically within 1 year.

This case with Circular; ring-shaped, anular lesions illustrates the importance of repeated testing for syphilis,especially in individuals with HIV/AIDS, keeping in mind the increase in the number of syphilis case reports and in the number of atypical presentations and morphological forms of"The Great Imitator" in the modern era.

It is worth testing for syphilis in patients with unexplained cutaneous rash, especially those who failed the standard therapy.

A 30-year-old man presented to the sexual health clinic with a rash on his face, hands, and feet that had appeared 1 month earlier. He had a history of human immunodeficiency virus infection; his most recent CD4+ T-cell count was 374 per cubic millimeter. He reported having had unprotected sexual intercourse 2 months earlier.

A physical examination showed circinate, concentric lesions on the palms (Panel A) and soles (Panel B). Multiple circinate lesions were also visible on the face, with areas of erosion at the oral commissures (Panel C). Condyloma latum was present in the perianal area, and patchy alopecia was visible on the scalp.

A Venereal Disease Research Laboratory (VDRL) test was positive at a titer of 1:32, which confirmed a diagnosis of syphilis. Tests for other sexually transmitted infections were negative. The patient was treated with intramuscular benzathine penicillin. At a follow-up visit 1 month after the initiation of treatment, all the lesions had completely resolved. A repeat VDRL test showed a reduced titer of 1:8.

DOI: 10.1056/NEJMicm2035514