Letter - Clinical
An unusual case of extragenital primary syphilis
Miguel Santos-Coelho
, Joana Alves Barbosa, Margarida Moura Valejo Coelho, Alexandre João
Corresponding author
Service of Dermatovenereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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The clinical history revealed the appearance of a pinkish papule, two months before, with progressive growth and subsequent ulceration, with no history of local trauma or similar lesions in the past.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective examination identified a painless ulcer, measuring 5 × 5 mm, on the dorsal side of the third finger of the right hand, with a bright red base and raised pinkish infiltrated borders (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). No local adenopathies were identified and the remaining clinical examination showed no alterations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Histopathology of a punch biopsy on the lesion border revealed a dense perivascular and interstitial lymphoplasmacytic infiltrate; immunohistochemical evaluation with anti-treponemal antibody staining showed massive epidermal, adnexal and vascular spirochete infiltration (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Laboratory assessment disclosed a positive FTA-ABS test and a VDRL title of 1/64. Serologies for the remaining sexually transmitted infections (HIV, hepatitis B and hepatitis C) were negative.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A diagnosis of primary extragenital syphilis was established and the patient was medicated with intramuscular benzathine penicillin G (2.4 million IU), in a single dose, with complete resolution of the lesion in the following weeks.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Syphilis is an infection caused by the spirochete <span class="elsevierStyleItalic">Treponema pallidum</span> subsp. <span class="elsevierStyleItalic">pallidum</span>. The main method of transmission involves skin or mucous membrane contact with an infectious lesion, usually through sexual contact. The remaining cases correspond mostly to vertical transmission of the disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Primary syphilis manifests through one or more asymptomatic ulcers at the site of inoculation, with characteristics similar to those described in the clinical case presented here, usually accompanied by local adenopathies. The lesion appears after a mean incubation period of three weeks (10–90 days), and the most common site for its development is the anogenital region.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the absence of treatment, healing occurs after a few weeks and about one-third of the patients develop manifestations of secondary syphilis later on.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Extragenital primary syphilis is a rare event, corresponding to 2%–7% of reported cases,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with the oral cavity being the most frequently affected area.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> The natural history, treatment, and prognosis of primary lesions do not depend on their location.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The clinical differential diagnosis of extragenital lesions is extensive and should be guided by the clinical history. Cutaneous mycobacteriosis, herpetic infections, cutaneous leishmaniasis, and squamous cell carcinoma are conditions that must be taken in consideration.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis is often made through a combination of clinical history, physical examination, and treponemal and non-treponemal serological tests. In this case, a skin biopsy was performed due to the atypical location of the lesion to exclude other etiologies. Direct darkfield examination and polymerase chain reaction (PCR) assessment are other diagnostic methods used sometimes.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This clinical case illustrates a rare presentation of primary syphilis and demonstrates the importance of this differential diagnosis in lesions with the aforementioned characteristics, regardless of their location.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors' contributions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Miguel Santos Coelho: Data survey, data analysis and interpretation; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Joana Alves Barbosa: Data survey, data analysis and interpretation; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; approval of the final version of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Margarida Moura Valejo Coelho: Critical review of the literature; approval of the final version of the manuscript.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Alexandre João: Data survey, data analysis and interpretation; collection, analysis, and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; approval of the final version of the manuscript.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors' contributions" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2022-08-06" "fechaAceptado" => "2022-09-06" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Service of Dermatovenereology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1446 "Ancho" => 1508 "Tamanyo" => 314948 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcer on the third finger of the right hand.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1305 "Ancho" => 1508 "Tamanyo" => 366764 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evaluation by immunohistochemistry with anti-treponemal antiserum in the skin sample (×200).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sexually acquired syphilis: historical aspects, microbiology, epidemiology, and clinical manifestations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.K. Forrestel" 1 => "C.L. Kovarik" 2 => "K.A. Katz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaad.2019.02.073" "Revista" => array:6 [ "tituloSerie" => "J Am Acad Dermatol." "fecha" => "2020" "volumen" => "82" "paginaInicial" => "1" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30986477" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2020 European guideline on the management of syphilis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Janier" 1 => "M. Unemo" 2 => "N. Dupin" 3 => "G.S. Tiplica" 4 => "M. Potočnik" 5 => "R. Patel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Eur Acad of Dermatol Venereol." "fecha" => "2020" "volumen" => "35" "paginaInicial" => "574" "paginaFinal" => "588" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary syphilis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Eccleston" 1 => "L. Collins" 2 => "S.P. Higgins" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1258/ijsa.2007.007258" "Revista" => array:6 [ "tituloSerie" => "Int J STD AIDS." "fecha" => "2008" "volumen" => "19" "paginaInicial" => "145" "paginaFinal" => "151" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18397550" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary syphilis of the oropharynx: an unusual location of a chancre" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Drago" 1 => "G. Ciccarese" 2 => "L. Cogorno" 3 => "C.F. Tomasini" 4 => "E.C. Cozzani" 5 => "S.F. Riva" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/0956462414551235" "Revista" => array:6 [ "tituloSerie" => "Int J STD AIDS." "fecha" => "2014" "volumen" => "26" "paginaInicial" => "679" "paginaFinal" => "681" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25193247" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/03650596/0000009900000002/v2_202407221312/S0365059623002556/v2_202407221312/en/main.assets" "Apartado" => array:4 [ "identificador" => "95691" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letter – Clinical" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009900000002/v2_202407221312/S0365059623002556/v2_202407221312/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623002556?idApp=UINPBA00008Z" ]
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