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A SO-Year-Old Man With Skin Lesions and Multiple Pulmonary Nodules: Diagnosis

Subsequent laboratory evaluation included the following: erythrocyte sedimentation rate, 49 mm/h; HIV by enzyme-linked immunosorbent assay, negative; viral hepatitis panel, negative; urine and blood cultures, no growth; skin biopsy fungal culture, no growth; antinuclear antibody, titer of 1:80 in a speckled pattern; rheumatoid factor, negative; and antineutrophil cytoplasmic antibody panel, negative. A purified protein derivative skin test was placed, and the result was negative.

What is the diagnosis?
Diagnosis: Secondary syphilis with pulmonary nodules
A rapid plasma reagin test result was positive, with a titer of > 1:256. A confirmatory fluorescent treponemal antibody absorption test result was positive at 4+ intensity,
An hematoxylin-eosin stain of a biopsy of a skin lesion revealed a heavy, deep dermal infiltrate that was composed of lymphocytes and histiocytes. The infiltrate was perivascular and was not associated with necrosis. Only a small number of plasma cells and neutrophils were present within the inflammatory infiltrate. By Warthin-Starry stain, there were spirochetes consistent with Treponema pallidum (Fig 3). buy glucophage
Syphilis is caused by the spirochete T pallidum. The natural course of the disease has been well described. Initially, there is an incubation period during which there is spirochetemia but no clinical symptoms. In approximately 3 weeks, the classic painless chancre, typically accompanied by regional lymphadenopathy, appears at the site of inoculation (primary syphilis). Two to 8 weeks after the chancre appears, secondary syphilis (or disseminated syphilis) develops. During this stage, there is rapid reproduction and dissemination of the spirochetes resulting in extensive clinical manifestations including, but not limited to, constitutional symptoms, skin involvement, and CNS involvement. A period of latent syphilis follows during which there are no clinical manifestations, yet there is the potential for relapse or transmission through contaminated blood. Finally, years after initial exposure, tertiary syphilis (or late syphilis) develops in some patients. This stage of disease, in which there is slowly progressive chronic inflammation, is characterized by gummas, granulomatous-like lesions that can occur in virtually any organ system including the CNS (parenchymal neurosyphilis), and endarteritis obliterans affecting the vaso vasorum of the aorta and the small vessels of the CNS (meningovascular neurosyphilis). Clinically, a host of neurologic problems can develop.
Figure 3. Spirochetes in dermal tissue from right forearm skin biopsy, Warthin-Starry stain (original X 1,000). The arrow indicates an organism measuring approximately 12 |j,m in length and demonstrating the classic coiled morphology consistent with T pallidum. A few additional organisms with less distinct morphology are present to the right of the arrow.