Lichenoid secondary syphilis

Argentina Case 1 A married, heterosexual, promiscuous, 29-year-old white man had experienced an asymptomatic eruption on the trunk and left palm for the last 3 months. After 2 months, the trunk involvement disappeared, but 2 weeks later lip and tongue lesions developed. No history of genital ulcer was found. The physical examination revealed asymptomatic, violaceous, erythematous, flat-topped papules in an annular pattern, 5–10 mm in size, on the left palm (Fig. 1). Painful vesicular lesions surrounded by a red halo, with erosions on the labial mucosa and defined areas of depapillation on the posterior aspect of the tongue, were observed. The genitalia and soles were free of lesions. The clinical findings suggested lichen planus or secondary syphilis. Figure 1. Flat-topped papules on the palm A biopsy specimen of the palm was consistent with a lichenoid dermatitis, with hyperkeratosis, parakeratosis, acanthosis, striking elongation of the rete ridges, leukocytic exocytosis, and sparse colloid bodies. A band-like dense lymphomonocytic infiltrate without plasma cells was present throughout the papillary dermis. The infiltrate obscured the dermo-epidermal interface (Fig. 2). A lip biopsy showed a subacute inflammatory dermatitis. Venereal Disease Research Laboratory (VDRL) titers were high (1/1024) and fluorescent treponemal antibody absorbed (FTA-ABS) test was positive. Enzyme-linked immunosorbent assay (ELISA) for human immunodeficiency virus (HIV) was negative. After two weekly doses of benzathine penicillin G (2.4 million units), all lesions cleared within 3 weeks. Figure 2. Parakeratosis and acanthosis with thinning of the rete ridges. Lichenoid infiltrates of lymphocytes and monocytes (hematoxylin and eosin; original magnification ×40) Case 2 A 42-year-old white man had developed cutaneous lesions involving the trunk and extremities over the past 2 weeks. Anorexia, malaise, and generalized arthralgia were also noted. He was married and denied casual sexual partners. Itching, erythematous, flat-topped papules with scaling and some crusts on the trunk and extremities were observed (Fig. 3). The palms and soles were free of lesions. The glans penis showed painless, erythematous, shallow erosions. Neck microlymphadenopathy was present. All other physical findings were normal. Figure 3. Lichenoid eruption on the trunk FTA-ABS and VDRL (1/1024) tests were reactive. ELISA for HIV was negative. The dark field microscopy examination of the glans penis exudate revealed Treponema pallidum with no spiraling motion. A biopsy specimen of the trunk showed a lichenoid dermatitis with increased numbers of perivascular and periadnexial plasma cells, in the superficial and deep dermis (Fig. 4). Two weekly doses of benzathine penicillin G Figure 4. Superficial perivascular dermatitis; dermo-epidermal interface lichenoid (hematoxylin and eosin; original magnification ×100) (2.4 million units) were given. All lesions faded in 3 weeks.