Our case patient met each of the Coleman criteria. His rash, lymphadenopathy, and constitutional symptoms of fevers, chills, night sweats, and weight loss were all well-described clinical manifestations of secondary syphilis. Serologic testing, including positive rapid plasma reagin and fluorescent treponemal antibody absorption test results, confirmed the disease. Chest imaging revealed multiple bilateral basilar nodules, and other possible etiologies (including Wegener granulomatosis, lymphoma, and tuberculosis) were excluded. Consistent with secondary syphilis, a Jarisch-Herxheimer reaction developed after the first infusion of penicillin, manifested by hypotension, tachycardia, fever as high as 39.4°C, rigors, myalgias, headache, and nausea. Two months after completing therapy, a follow-up CT scan of the chest revealed near-complete resolution of the pulmonary nodules (Fig 4).
A lumbar puncture sampling of cerebral spinal fluid was performed in our case, as the CNS is involved in up to 40% of patients with secondary syphilis. Analysis revealed the following: WBCs, 31/^L; lymphocytes, 53%; mononuclear cells, 26%; neutrophils, 21%; glucose, 40 mg/dL; protein, 82 mg/dL (normal range, 15 to 45 mg/dL); Venereal Disease Research Laboratory titer, 1:8; fluorescent treponemal antibody absorption test, positive at 4+ intensity; Gram stain, negative; and culture, no growth. As a result of these findings, the patient was treated with IV rather than IM penicillin G. generic wellbutrin
Three months after presentation, the renal abnormalities had also resolved. Laboratory testing showed the following: creatinine, 1.1 mg/dL; urinalysis, no protein, glucose, or casts; and erythrocyte sedimentation rate, 28 mm/h.
The differential diagnosis for pulmonary nodules accompanied by cutaneous lesions is extensive. It typically includes metastatic malignancies, lymphoma, Kaposi sarcoma, Wegener granulomatosis, sarcoidosis, rheumatoid arthritis, tuberculosis, invasive aspergillosis, histoplasmosis, coccidiomycosis, and septic emboli. This case, only the second reported of multiple pulmonary nodules associated with secondary syphilis, demonstrates that the presence of pulmonary findings on radiographic imaging does not exclude the diagnosis of secondary syphilis. The historical epithet for syphilis—The Great Imitator—remains appropriate.
Figure 4. CT scan of the chest 2 months after penicillin therapy demonstrating resolution of the bibasilar pulmonary nodules.