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Granulomatous Secondary Syphilis: An Uncommon Presentation of the Great Imitator

Published:September 28, 2022DOI:https://doi.org/10.1016/j.amjmed.2022.09.014
      A 20-year-old man presented with a 6-week history of multiple erythematous, tender, enlarging nodules on his forehead, nose, and forearm, accompanied by severe headaches and photophobia, and fatigue. He showed little improvement on systemic steroid taper. Physical examination revealed 2 well-defined erythematous nodules measuring 1 cm × 0.5 cm on the forehead, with numerous others on the upper arms (Figure 1). Nodules on the forehead were accompanied by lymphadenopathy in the cervical region. Punch biopsy of the lesion revealed a dense dermal granulomatous infiltrate with lymphocytes and numerous plasma cells (Figure 2). Immunohistochemical staining for Treponema pallidum identified numerous spirochetes, confirming a diagnosis of secondary syphilis. Treatment with benzathine penicillin G resulted in the complete resolution of symptoms.
      Figure 1
      Figure 1Multiple erythematous nodules and subcutaneous mass on the forehead.
      Figure 2
      Figure 2Histology of forehead lesion revealing a dense dermal granulomatous infiltrate with lymphocytes and numerous plasma cells (red arrow) in (A) 10× and (B) lower power in hematoxylin and eosin stain.
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