Secondary syphilis: a multisystem disease not to be forgotten

Abstract

A42-year-old homosexual man presented with a 3-month history of painful mouth ulcers and a hyperkeratotic, erythematous scaly rash affecting his palms and soles (Figure 1). He also had a 2-month history of bilateral anterior tibial pain, balanitis and a panuveitis. There was a recent history of a non-specific urethritis and a past history of shingles. In addition to the rash affecting his palms and soles, he had facial seborrhoeic dermatitis, mucosal ulceration with leukoplakia, and a balanitis with phimosis. A tender firm lump was noted over his left anterior shin. He was apyrexial and there was no lymphadenopathy or hepatosplenomegaly. Routine investigations revealed a raised erythrocyte sedimentation rate of 42 mm/h, associated with a polyclonal rise of immunoglobulins with a normal full blood count and C-reactive protein. A plantar skin biopsy showed numerous plasma cells in addition to lymphocytes within the papillary dermis (Figure 2). A Warthin–Starry stain for bacteria was negative. At the same time as the skin biopsy his vision worsened with bilateral mid-peripheral retinitis in addition to panuveitis. The skin biopsy showing numerous plasma cells and the mid-peripheral distribution of the retinitis were highly suggestive of secondary syphilis. The diagnosis of secondary syphilis was confirmed by a positive venereal disease research laboratory (VDRL) titre of 1:256, in association with a positive fluorescent treponemal antibody (FTA) test and treponema pallidum haemagglutination assay. He was also found to be positive for human immunodeficiency virus with a CD4 (t-helper cell) count of 145 × 106/litre (10.5%), and a viral load of 115 305 copies/ml. X-rays of his tibial bones revealed bilateral lytic cortical lesions, in keeping with a syphilitic osteitis. The firm tender lump over his left shin corresponded to a cortical lesion with a marked periosteal reaction (Figure 3). He was given a 10-day course of high-dose intravenous benzylpenicillin, after which his skin and mucosal lesions had almost resolved. The initial ocular inflammatory reaction settled quickly but visual acuity deteriorated 2 days after the commencement of penicillin, thought to result from an intraocular Jarisch–Herxheimer reaction. This complication was treated with a tapering dose of oral prednisolone, starting at a dose of 60 mg/day. His visual acuity subsequently returned to normal leaving a residual typical ‘salt and pepper’ scarring in the fundus (Figure 4).