A case of secondary syphilis masquerading as cutaneous lymphoma

Kevin Nethers,Rafael E Mojica,Etan Marks,Robin Burger,Sadia Saeed,William Steffes

doi:10.1016/j.jdcr.2021.05.036

Abstract

A case of secondary syphilis masquerading as cutaneous lymphoma

Highlights

Secondary syphilis presents as a generalized nonpruritic papulosquamous eruption, which may include the palms and soles, typically occuring 3 to 10 weeks after the initial spirochete inoculation.[1,2] Numerous unusual presentations have been reported, including but not limited to, annular or figurative plaques, ‘‘moth-eaten’’ alopecia, polymorphic papules, granulomatous nodules, crusted nodules, and nail changes.[3]
The differential was broad, the clinical presentation was concerning for lymphomatoid papulosis
Syphilis has been widely documented as mimicking other diseases clinically as well as histologically; syphilis mimicking cutaneous lymphoma/lymphoreticular disease has seldomly been reported.[1,2,3,5,67]

Summary

INTRODUCTION

Secondary syphilis presents as a generalized nonpruritic papulosquamous eruption, which may include the palms and soles, typically occuring 3 to 10 weeks after the initial spirochete inoculation.[1,2] Numerous unusual presentations have been reported, including but not limited to, annular or figurative plaques, ‘‘moth-eaten’’ alopecia, polymorphic papules, granulomatous nodules, crusted nodules, and nail changes.[3]. Both specimens demonstrated a dense superficial and deep perivascular and periadnexal dermal infiltrate comprised mostly of small lymphocytes, some medium-sized lymphocytes, and a few plasma cells and histiocytes (Fig 2). Both biopsies showed polyclonal results via kappa and lambda in situ hybridization studies. The forearm specimen exhibited negative T-cell receptor beta gene rearrangement; the biopsy was positive for T-cell receptor gamma gene rearrangement (demonstrating the same clonal pattern as that observed in the epigastric skin biopsy). B-cell clonality studies were negative for both specimens These molecular findings raised concern for a T-cell lymphoproliferative disorder, a reactive clonal expansion could not be completely ruled out. Upon the follow-up visit with dermatology, 7 weeks from the initial visit, the patient showed a more generalized papulosquamous rash (Fig 3) on the trunk and extremities (but not palms and soles). The identical T-cell clonality in the 2 initial biopsies was attributed to a reactive process

DISCUSSION

Epidermotropism of atypical Atypical lymphohistiocytic Thinning of the epidermis