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JAMA Dermatology Clinicopathological Challenge
July 2016

Abrupt Onset of Ulcerative Papules and Nodules on the Face and Genitals

Author Affiliations
  • 1Department of Dermatology, Howard University Hospital, Washington, DC
  • 2The Wright Center for Graduate Medical Education, Washington, DC
  • 3Veterans Affairs Medical Center, Washington, DC
JAMA Dermatol. 2016;152(7):829-830. doi:10.1001/jamadermatol.2016.0017

A man in his 60s with a medical history of hypertension, cerebrovascular accident, colon cancer, and remote cocaine use presented with numerous pruritic crusted papules and nodules on the face and genitals. The eruption presented abruptly over a 2-week course, and the patient attributed it to contact with plants while working in his yard. He denied having similar lesions in the past. He had used over-the-counter topical antibiotic and antihistamine creams, which alleviated the pruritus. He denied recent sexual intercourse, penile discharge, fevers, chills, nausea, or vomiting. Physical examination of the bilateral cheeks, glabella, dorsal nose, and chin revealed multiple skin-colored papules, nodules, and vegetative plaques ranging in size from 4 to 6 mm in diameter, with central umbilication, erosions, and overlying yellow crust (Figure, A). There were similar lesions on the scrotum and inner thighs, with sparing of the penis (Figure, B). There was also a 1-cm ulceration on the left lower lip. The palms and soles were spared. There was no lymphadenopathy noted. One 4-mm punch biopsy specimen was obtained from a nodule on the left medial cheek, bisectioned, and sent for both hematoxylin–eosin staining and tissue cultures for bacteria, fungi, and atypical mycobacteria (Figure, C and D).

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    1 Comment for this article
    Neurosyphilis Evaluation in Persons with Syphilis
    Kenneth A. Katz MD MSc MSCE, Ata S. Moshiri MD MPH, Stephanie E. Cohen MD MPH | Katz: Department of Dermatology, Kaiser Permanente, Pleasanton, CA; Moshiri: Department of Dermatology, University of Pennsylvania, Philadelphia, PA; Cohen: San Francisco Department of Public Health,
    As the incidence of syphilis rises in the United States, dermatologists’ competence in diagnosing and managing syphilis is increasingly important. A recent article1 described a case of lues maligna, a manifestation of secondary syphilis, in a man without neurologic or ophthalmic abnormalities. A lumbar puncture showed cerebrospinal fluid (CSF) pleocytosis, leading to intravenous penicillin treatment, “out of concern for tertiary syphilis.”1 The case raises important issues related to neurosyphilis in persons with syphilis.

    First, neurosyphilis can occur during any stage of syphilis, not just during tertiary syphilis.2 Neurosyphilis is classified as early or late. Late neurosyphilis includes tabes dorsalis and
    general paresis.2 Early neurosyphilis includes neurologic and ophthalmologic manifestations occurring before or during primary, secondary, or early latent syphilis.2 In one study, early neurosyphilis (manifesting as cranial nerve abnormalities, meningitis, stroke, headache, and/or altered mental status ) affected 1.7 percent of persons, of whom 30 percent experienced persistent symptoms six months after treatment.3 More recently, clusters of ocular syphilis cases, including uveitis and vision loss, have occurred in several U.S. cities.4 For those reasons, CDC recommends assessing every person with syphilis for neurologic and ophthalmic disease.5

    Second, cerebrospinal fluid (CSF) examination should be limited to specific scenarios. CSF abnormalities, including pleocytosis, are common but not necessarily clinically significant in adults with primary or secondary syphilis.5 Therefore, CDC limits indications for CSF examination to the following: neurologic or ophthalmic symptoms or signs suggestive of neurosyphilis; treatment failure; or tertiary syphilis.5 Neither high-titer disease nor lues maligna is, in and of itself, an indication for CSF examination, according to current CDC guidelines.5

    Evaluation for neurosyphilis is a critical part of managing syphilis5, including for dermatologists. Effective neurosyphilis evaluation can lead to prompt diagnosis and care, forestalling potentially permanent sequelae. Equally importantly, guideline-based evaluation for neurosyphilis can avert unnecessary procedures and treatment when not required.

    1. Payne LC, Egan KM, Aziz N. Abrupt Onset of Ulcerative Papules and Nodules on the Face and Genitals. JAMA Dermatology. Published online March 2, 2016.
    2. Marra CM. Update on neurosyphilis. Curr Infect Dis Rep. 2009;11:127-34.
    3. CDC. Symptomatic early neurosyphilis among HIV-positive men who have sex with men – four cities, United States, January 2002-June 2004. MMWR 2007;56:625-8. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a1.htm.
    4. Woolston S, Cohen SE, Fanfair RN, et al. A Cluster of Ocular Syphilis Cases – Seattle, Washington, and San Francisco, California, 2014-2015. MMWR. 2015;64:1150-1. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6440a6.htm.
    5. Workowski KA, Bolan GA. STD Treatment Guidelines 2015. MMWR Recomm Rep 2015;64(RR-03):1-137.