Malignant Syphilis in a Female Patient: A Case Report and Mini-Review

Abstract

Malignant syphilis (MS) is a rare form of secondary syphilis with grotesque skin lesions, systemic manifestation and life-threatening complications. This article presents a case of MS in an immunocompetent 41-year-old female, who initially manifested with a generalized nonpruritic erythematous rash and systemic symptoms. She was mistreated for generalized impetigo and hepatitis attributed to chronic alcoholism. After partial recovery and a 3-month latent period, she developed infiltrated plaques with crusts on the trunk, head and neck; pharyngitis and laryngeal lesions; generalized lymphadenopathy and nonspecific systemic symptoms. Serologic tests confirmed syphilis, and cerebrospinal fluid analyses indicated the presence of anti-treponemal antibodies. Urine drug screening was positive for cannabinoids. The polymerase chain reaction from skin biopsy samples identified T. pallidum, confirmed with Warthin-Starry staining. Immunohistochemical analysis was uncharacteristic. Tertiary syphilis, neurosyphilis, ocular syphilis and otosyphilis were excluded. However, the patient was treated for neurosyphilis with benzylpenicillin (18 million IU intravenously daily, 14 days) and corticosteroids. No Jarisch-Herxheimer reaction occurred. Ten months after treatment, residual scars were visible, and 1 year later, she attempted suicide. Since MS can resemble other diseases, it should be suspected in a mentally ill patient with chronic drug abuse, systemic nonspecific manifestations and dermatological abnormalities, including the head and neck region.

Keywords: dermatology; diagnostic errors; otolaryngology; sexually transmitted diseases; syphilis serodiagnosis.

Figure 1

Female patient with malignant syphilis. (A) Extensive plaques with crusts and erosions on her face at initial presentation. (B) Annular lesions with crusts on the torso (tattoos are concealed). (C) Extensive plaques, ulcers and erosions. Crusts were removed with ointment treatment. Diffuse swelling of the nasal soft tissues is visible. (D) Right-sided tonsillar plaque, consistent with syphilitic angina. The posterior oropharyngeal wall is hyperemic (N.B. enhanced vascular pattern).

Figure 2

Histopathology analysis of biopsy specimens of a patient with secondary malignant syphilis. (A,B) Suprascapular skin biopsy sample under low (A) and higher (B) magnification. Within the superficial and mid dermis is a dense, diffuse inflammatory infiltrate composed mainly of atypical T-cells, numerous plasma cells and histiocytes. (C) Facial skin biopsy: Warthin–Starry staining identified spirochetes.

Figure 3

Residual scars on the face and neck 10 months after treatment of malignant syphilis.