Sir, A previously healthy 35-year-old male presented with complaints of swelling of penis with inability to retract foreskin and dark-colored lesions on scrotum for 20 days. There was a history of unprotected sexual exposure with a female commercial sex worker 3 months back. One month later, he developed a solitary, painless ulcer on the penis. The patient opted for over-the-counter topical and systemic antibiotics following which the ulcer healed in the next 4–5 weeks. However, 2 weeks later, he developed swelling of the penis with inability to retract the foreskin, dark-colored asymptomatic lesions on scrotum and dark-colored scaly rash on palms and soles. There was no history of any urethral discharge, burning micturition or any constitutional symptoms. On examination, the patient had edema of the prepuce with secondary phimosis [Figure 1a]. There were multiple, violaceous, scaly plaques on scrotum [Figure 1b]. Palms [Figure 2a] and soles [Figure 2b] had multiple hyperpigmented macules with few keratotic papules. The mucosae, scalp and nails were unremarkable. He had multiple, discrete, non-tender, shotty lymph nodes (1–2 cm in diameter) in both inguinal regions. The hematological and biochemical investigations were normal. The venereal disease research laboratory (VDRL) test was reactive in a titer of 1:128 and Treponema pallidum hemagglutination assay (TPHA) was positive. ELISA (enzyme-linked immunosorbent assay) for HIV was negative. Our patient denied consent for skin biopsy. In the setting of corroborative history, examination and reactive serological tests, a final diagnosis of secondary syphilis was made. The patient was treated with a single dose of benzathine penicillin 2.4 million units (1.2 million units given in each buttock) after sensitivity testing. He was counseled about safe sexual practices and was asked to get his wife evaluated too.Figure 1: (a) Edema of the prepuce with secondary phimosis; (b) violaceous, scaly plaques on the scrotumFigure 2: (a) Hyperpigmented macules on both palms; (b) hyperpigmented, keratotic papules on both solesWhen the patient was reviewed 6 weeks later, the penile edema and the scrotal lesions had resolved and a healed atrophic scar was appreciable on the undersurface of the prepuce [Figure 3]. A repeat VDRL titer 3 months post treatment was 1:32, indicating adequate response to the treatment.Figure 3: Healed atrophic scar on the undersurface of the prepuce (solid black arrow)Discussion Secondary syphilis is often called “the great mimicker” because of its protean clinical presentations.[1] Skin rash is seen in more than 80%–95% of cases with over 95% of the eruptions being macular, maculo-papular or papular lesions. Rare variants include nodular, pustular, lichenoid and erythema multiforme like lesions. Penile edema is usually a feature of syphilitic balanitis seen in primary syphilis. Our patient had unusual lichenoid lesion on scrotum associated with penile edema resulting in secondary phimosis. He did not have any systemic involvement or generalized rash on body. Only because he had typical lesions on palms and soles did we consider the possibility that the scrotal lesions and penile edema were possible manifestations of secondary syphilis, which was later confirmed by serological tests. Lichenoid lesions on scrotum as a manifestation of secondary syphilis was previously reported by Narang et al. in two cases who also had generalized lymphadenopathy, fever and malaise.[2] Also, scrotal eczema-like presentation in syphilis has been rarely mentioned in literature.[3] Therefore, one must keep a high index of suspicion of syphilis in a patient presenting with a temporal history of high risk sexual behavior and cutaneous manifestations that can easily be confused with common dermatoses like lichen planus, psoriasis, tinea, eczema, etc. Penile edema is usually seen as a manifestation of syphilitic or Follmann's balanitis[4] in the primary stage and usually resolves with the resolution of the chancre. In our patient, the penile edema may have been a manifestation of chancre redux which went unnoticed due to secondary phimosis or could have been a rare manifestation of secondary syphilis itself as has been described by Korta et al.[5] To conclude, clinical presentations of secondary syphilis are protean and might be misleading. It is important that a high index of suspicion is maintained when evaluating lesions in patients at epidemiologic risk for syphilis and any suspicion should be dealt accordingly with appropriate investigations. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgements We are thankful to the family of our patient for their support and cooperation.
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Jun 22, 2019
Eric S Schafer 
Open Access
