P2.56 A reminder from the great imitator – gummatous syphilis of the nasal cavity with septal perforation

Introduction Gummatous syphilis presenting as nasal septal perforation is well described in the classic literature, but rarely encountered in the current antibiotic era. We present a man with a destructive nasal process with a delayed diagnosis of tertiary (late benign) syphilis. Case Description A 45 year old Eritrean gentleman presented with an ulcero-nodular lesion of the left nares, progressive over the previous six months. He denied trauma or illicit drug inhalation. Exam was remarkable for left nasal cavity with an eroding destructive lesion perforating through the nasal septum and left nasal ala. He had no clinical signs or symptoms of neurosyphilis. Multiple biopsies revealed acute-on-chronic inflammation with focal necrosis and no evidence of malignancy. Fungal, treponemal and routine bacterial stains were negative, and tissue cultures were negative. Imaging indicated no bony destruction. The patient was treated for presumed cellulitis with multiple courses of oral antibiotics (cephalexin, amoxicillin) with no improvement in symptoms. At follow up, the patient tested negative for human immunodeficiency virus (HIV) infection and negative for anti-neutrophil cytoplasmic antibodies (ANCA). Serologic tests for syphilis were ultimately performed, revealing a rapid plasma reagin (RPR) titer of 1:512 with a reactive florescent treponemal antibody absorption test (FTA-ABS). A CSF evaluation was normal, with no pleocytosis and normal protein and glucose. Treatment was initiated with benzathine penicillin G, three doses of 2.4 million units each at one-week intervals. Clinical response to treatment is pending at the time of this report. Discussion Gummatous syphilis is of clinical importance because of its potential for local destruction and disfigurement of the nasal structures. Early recognition and management has important individual and public health implications and this case would remind contemporary physicians that “the great imitator” could lurk behind unusual presentations.