Tuberoserpiginous lesions in a 50-year-old patient with hand eczema: a quiz case

Excerpt

A 50-year-old man presented to our clinic with disseminating hand eczema. Physical examination revealed not only dyshidrotic hand eczema but also asymmetric, tubero-serpiginous lesions on the patient’s left forearm, left hand, and back (Fig. 1a, b). The eruptions were first observed 2 months previously, showed a tendency toward central healing and peripheral extension, and were not itchy. The following differential diagnoses were considered: spreading eczema, tinea corporis, erythema gyratum repens, tuberculosis, tubero-serpiginous syphilis, and sarcoidosis. Histological examination revealed a dense, granulomatous, and lymphocytic cell infiltration with plasma cells (Fig. 2a, b). The Venereal Disease Research Laboratory (VDRL) assay was titrated to 1/64 and the Treponema pallidum hemagglutination assay (TPHA) to 1/40,960. Cerebrospinal fluid examination tested positive for neurosyphilis. The patient had a history of unprotected sexual intercourse with other men and also had a history of a penile lesion three years previously. At that time syphilis was diagnosed, and the patient was treated with a single intramuscular injection, most likely benzylpenicillin. Since that time the patient had not undergone serological investigation for syphilis. We diagnosed tertiary cutaneous syphilis with tubero-serpiginous syphilides and asymptomatic neurosyphilis. The patient was started on a 2-week course course of penicillin G administered intravenously. The syphilides totally regressed within 4 months, whereas the VDRL was titrated to 1/16 and TPHA to 1/20,480.

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