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Virtual case of the month
Unusual presentation of a skin rash
  1. Rajendra Singh,
  2. David Teranno
  1. Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Rajendra Singh, Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine, 1 Gustave L. Levy Place, Box-1194, New York, NY 10029, USA; rajendra.singh{at}mountsinai.org

https://doi.org/10.1136/jclinpath-2016-204007

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    Clinical question

    A 44-year-old man with erythema and oedema of the left abdomen. The duration of the lesion is unknown. Review the high-quality, interactive digital Aperio slide at http://virtualacp.com/JCPCases/jclinpath-2016-204007/ and consider your diagnosis.

    What is your diagnosis?

    1. Viral xanthem

    2. Bacterial folliculitis

    3. Secondary syphilis

    4. Collagen vascular disease

    5. Linear IgA

    ANSWER

    C Secondary syphilis

    Discussion

    The incidence of syphilis has been increasing in the USA since 2001.1 The histology of syphilis, though widely studied, still remains a diagnostic challenge, particularly when the clinical presentation does not suggest the diagnosis. We present an overview of the clinical and pathological features commonly associated with cutaneous primary and secondary syphilis, addressing, at the end, the current case.

    Treponema pallidum,2 as is well known, is the etiological organism of syphilis. Syphilis presents in one of three stages—primary, secondary and tertiary—with primary and secondary syphilis being the most common. Secondary syphilis is most commonly encountered in dermatopathology practice. The anogenital region is the most common location. However, 5% of cases arise in extragenital sites, which are termed endemic, or non-venereal, syphilis. The oral cavity is the most commonly involved extragenital site, but any site can be involved.

    In primary syphilis, the lesion typically appears as a chancre, a punched-out, painless ulcer that develops 20–30 days after exposure to T. pallidum and may be associated with painless lymphadenopathy. These lesions resolve within 1–5 weeks and do not scar.

    Secondary syphilis arises 6–8 weeks after the primary chancre. The lesions initially present as 5–10 mm erythematous macules on the head, …

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