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syphilis has been hardly reported&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Besides typical exanthema and lesions on the mucous membrane&#44; secondary syphilis may present atypical manifestations which imitate various dermatoses&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> An unusual clinical presentation is Nodular syphilis&#44; characterized by nodules and plaques whose histology shows granulomas and plasma cells&#44; with nearly 30 reported cases&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Another infrequent presentation is the appearance of rapidly evolving erythematous plaques similar to SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This case is presented since there are few reports published in the literature on the SS and nodular syphilis association&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 20-year-old woman&#44; without previous morbid history&#44; presented for 20-days painful and progressive extension of cutaneous lesions&#44; starting on the face and subsequent involvement of the trunk and extremities&#44; related to noticeable general systemic symptoms&#44; such as headache&#44; and fever&#46; On the physical examination&#44; she presents numerous papules&#44; plaques&#44; and erythematous nodules on the face&#44; chest and back&#44; abdomen&#44; forearm&#44; muscles&#44; ankles&#44; palms of the hands and the soles of her feet&#44; some vesicular and pustular lesions in the abdomen and ankle&#44; presence of pink-erythematous lesion on the vaginal opening &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Given the suspicion of neutrophilic dermatosis&#44; skin incisional biopsies were performed in the left temple region that showed superficial and deep non-tuberculoid granulomatous dermatitis&#44; with the presence of plasma cells &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; and in the abdominal region that showed noticeable subepidermal edema associated with dense infiltrate of polymorphonuclear neutrophils in the superficial and middle dermis&#44; without vasculitis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Hospitalization and blood tests were indicated&#58; Hemoglobin&#58; 11&#46;3&#8239;g&#47;dL&#44; leukocytes&#58; 17&#46;300&#8239;&#181;L with the segmentation of 86&#37;&#44; CRP&#58; 329&#8239;mg&#47;L&#44; HIV&#58; non-reactive&#44; HbsAg&#58; non-reactive&#44; HCV&#58; non-reactive&#46; VDRL&#58; reactive 1&#47;16 dilution&#44; MHA-TP&#58; reactive&#46; With these findings&#44; she was diagnosed with secondary syphilis associated with the SS&#46; Benzathine penicillin G 2&#46;4 MUI twice a week and prednisone 1&#8239;mg&#47;kg per day were prescribed&#46; After the first dose of penicillin&#44; the patient reacted with fever&#44; tachycardia&#44; and increased inflammatory parameters&#44; which were interpreted as a Jarisch Herxheimer reaction&#44; when most of the lesions took a pustular aspect &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; After 3-months&#44; atrophic scars were observed on the face and the trunk&#44; erythematous atrophic scar with an anetodermal appearance and post-inflammatory hyperpigmentation without recurrence of lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Syphilis and SS association has been poorly reported&#46; The first published case dated from 1986 when the authors analyzed whether syphilis was the cause of or simulated SS&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Regarding syphilis&#44; it is known as a great imitator given the wide variety of clinical presentations&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> An unusual form is nodular syphilis&#44; which presents with erythematous plaques and nodules&#44; whose histopathology exam frequently shows granulomas and plasma cells&#44; compatible findings with one of our patient&#8217;s biopsies&#46; The latter&#44; added to characteristics skin lesions and treponemal tests&#44; are consistent with the clinical picture of secondary nodular syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In relation to SS&#44; it is diagnosed based on clinical&#44; analytical&#44; and histological criteria&#46; The criteria were proposed in 1986 and reviewed by Von den Driesch in 1994&#44; where states that to make the diagnosis&#44; two major criteria and two minor criteria must be met&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our case&#44; the patient meets two major criteria &#40;sudden appearance of painful erythematous nodules and plaques&#59; dense neutrophilic infiltrate&#41; and the 4 minor criteria &#40;fever&#44; association with infection&#44; increased inflammatory parameters&#44; and good response to systemic corticosteroids&#41;&#44; confirming the diagnosis of SS&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The particularity of this clinical case is based on the rare association of these two pathologies&#44; added to an unusual presentation of nodular syphilis and the presence of two characteristic histological patterns in the same patient&#46; To our knowledge&#44; there are no reports of cases that comply with both the clinical and histology of nodular syphilis to date&#44; and also with a diagnostic criteria for SS&#46; The clinical importance of this first report highlights the need&#44; in the case of polymorphic clinical presentations&#44; to perform multiple biopsies on the diverse lesions&#44; which allows us to obtain more information regarding the studied pathology&#46; In addition to carrying out the infectious etiological search for syphilis in patients with symptoms compatible with SS&#44; since&#44; despite its low clinical frequency&#44; it implies a sexually transmitted disease with successful medical treatment&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217; contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Claudio Escanilla&#58; Design of the study and acquisition of data&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Yerco Goldman&#58; Design of the study&#44; acquisition of data and&#44; drafting the article&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Francisco Bobadilla&#58; Interpretation of data&#44; drafting the article&#44; and revising it critically&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Laura Segovia&#58; Interpretation of data&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Sweet syndrome is an inflammatory disease characterized by fever&#44; neutrophilia&#44; papules and erythematous plaques&#44; and a skin neutrophilic infiltrate&#46; Syphilis has been reported among the infectious causes of Sweet syndrome&#46; Syphilis can present atypical manifestations&#59; a rare presentation is nodular syphilis&#44; characterized by nodules with granulomas and plasma cells at histopathology&#46; This case report presents a 20-year-old woman patient&#44; with plaques and nodules&#44; and systemic symptoms&#46; The histopathological exam revealed both non-tuberculoid granulomas and a dense infiltration of polymorphonuclear neutrophils in the dermis&#46; These findings&#44; plus laboratory abnormalities&#44; characteristic of both conditions&#44; were conclusive for Sweet syndrome and nodular syphilis association&#46;</p></span>"
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