| BRIO803360 E-Mail Pedido:080508-188 Usuario: Cutis Dharmadhikari NJ; Joshi VR / artigos.fps@gmail.com 41997 59(3) pags. 135-7 / Sule RR; Deshpande SG; syphilis. (ian) MEDLINE_ 1997-2008 pmid: 9071852] hngpscadbiremebrieg-binwilexesead BRI0803360 E-Mail: artigos.fps@gmail.com Cutis 1997 59(3) pags. 135-7 / Sule RR; Deshpande SG; Dharmadhikari NJ; Joshi VR /-Late cutaneous Late cutaneous | Fonte de referéncia:(ish) MEDLINE_1997-2008 pmid: | syphilis. [iah) MEDLINE. 1997-2008 pmid: 9071552) sortss2 =r Local: BR1.1 Opedes: BR.t /BROG.1 /BR734.1 | Atendido / Paginas: 1 | Rejeitado / Motivo: | 53/156 Associacio Pele Saudavel S “4 ‘Av Arnolfo Azevedo 160 Pacaembu Ph + | |01236-030 - Sdo Paulo - SP — |BRASIL, 1 Pedido:080508-188Late Cutaneous Syphilis Rajiv R. Sule, MD, Pune, India Shridhar G. Deshpande, MD, Pune, India ‘Neeta J. Dharmadhikari, MD, Pune, India Vineeta R. Joshi, MBBS, Pune, India Late cutaneous syphilis has become a rarity as a result of effective treatment of early and latent syphilis with antibiotics. Superficial nodular lesions of late cutaneous syphilis should be differentiated from conditions including sarcoidosis, leprosy, lupus vulgaris, and granuloma annulare. We report the case of a 50-year-old woman with superficial nodular le- sions of late cutaneous syphili S phil is one ofthe most fascinating diseases of hur ‘mans. Itwas one of the most common infections in the past Late benign syphilis represents an inflam- matory process, either proliferative or destructive (gum- ‘matous), that involves structures generally not essential to the maintenance of life. The overwhelming majority of these manifestations occur in skin and bones? Late cuta- neous syphilis has now become a rarity, as a result of in- tensive case findings followed by effective treatment of ‘arly and latent syphilis with antibiotics’ We report a case of late cutaneous syphilis in a 50-year-old woman, Case Report A S0-yearold woman presented with skin lesions on her Fight hand and fae that had been present for two months, ‘They started as skincolored papules and a few coalesced {o form annular lesions on the dorsum of her Fight han. She had no history of diabetes metus, hypertension, is chemic heart disease or tuberculosis. She had been mar. tied for tity years and was living with her husband, and denied any history of extramarital intercourse or genital uk cerative disease. She had two healthy children and had had no abortions ‘The examination, revealed skincolored dome- shaped papular lesions 02 to 1 cm on her nose, cheeks, ‘ears, and eyes (Figure I). On the righthand they éoalesced {o form an annular lesion and plaques (Figure 2). These le sions were shiny, nonscaly, nontender, frm, and attached to skin, Generalized lymphadenopathy was not present and systemic examination revealed no abnormality. Results of her hemogram, urine examination, bio- chemical investigations, and lipid profile were within nor- FIGURE 1. Papular tesions on the face. From the Department of Dermatology 8. J. Medical Cologe and Sassoon General Hospital, Pune india REPRINT REQUESTS to Gadre Chambers, Flat No. 4, 1358 Sadashiv peth, Pune 411030, india (Dr Sule), ‘VOLUME 59, MARCH 1997 435FIGURE 2. Papules coalesced to form plaques and ‘annular lesion on the right hand. FIGURE 4, Granulomas showing macrophages, his- tioeytes, plasma cells, and epithelioid cells (H&E; original magnification, X 450). ‘mal limits, X-ray study of the chest was normal. The slit ‘Skin smear for Mycobacterium leprae on Zieh! Neelsen Staining revealed. no bacilli. Serologic test for syphilis Showed the VDRL test reactive in 1:32 dilution and the TPHA in 1:128 dilution, Serologic tests for human immuno- deficiency virus (HIV) 1 and 2 were negative. Results of hher cerebrospinal fluid examination were within normal limits and results of a VDRL test of cerebrospinal fluid were: nonreactive. Ultrasonographic studies of the abdomen and Xray studies of the skull did not reveal any abnormality. ‘Serologic tests for syphilis and HIV were nonreactive in her jhusband, A specimen from the annular lesion on her hand FIGURE 8. Focal granulomas in dermis without caseation (H&E; original magnification, X 100). FIGURE 5. Complete healing of the lesions on the right hand after treatment with penicillin. ‘showed several granulomas in the dermis (Figure 3), They ‘were composed of macrophages, lymphocytes, plasma tells, and epithelioid cells. The blood vessels showed endothelial swelling with perivascular infiltrate by lym phocytes and plasma cells Figure 4). She was treated with Injectable benvathine, penicillin, 24 million units intra muscularly after sensitivity testing, every week for three ‘weeks. The skin lesions started regressing after the first injection and completely regressed until the third injection (Figure 5). The results ofa repeat serologic test for syphilis stthe end of two moos aie wextment declined to a titer 18. see a a ean aay ieee gE tre ies opi a0 conshe RE a vs ent ra i a ys Sate t 15.8 percent of patients at some time sustained late benign lesions of the skin, mucous membranes, bones, ot joints. ie ie hoeerocees ree oie eaten er down to form punched out ulcers. The nodular lesions of sang taneous rot lis are rounded, dull ro painless, and aaa arene coer Sie eeeten gar arke eyo oaran ceteces Cs ieauce Rear generalized lymphadenopathy or constitutional symptoms. foeenren vemerere foe spate madre Sh aacare casemee case. The patient probably had had premarital intercourse. eaoareaeler sore ‘Nodular lesions of late cutaneous syphilis are characterized eee i eee caseation necrosis is not extensive and may be absent. The ecaeammce se ings are consistent with those in our case. ‘The nodular lesions of late cutaneous ils should be differentiated from sarcoidosis, leprosy, lupus ‘vulgaris, lupus miliaris disseminatus faciei, and granuloma annulare. Possibility of leprosy, which is endemic in thi part of the world, was excluded by negative results of a skin smear for Mycobacterium leprae and absence of typical ‘granulomas on histologic examination, Late cutaneous syphilis is always associated with reactive reagin test in high titer, as in this case. They can be differentiated from lesions of secondary syphilis, since they are painless and asymmetrical, and there is absence of constitutional symp- toms and lymphadenopathy. Penicillin remains the drug of choice for the treat- ‘ment of late cutaneous syphilis, and response to treatment is excelent. When esabhshing a finite diagnosis is dit ficult, a therapeutic trial with penicillin will result in Healing Thue is worth to pote tal te cutaneous syphilis is still around, even though the widespread use: Penicilin keeps it in the background, REFERENCES 4. Rosaln PD: Autopsy studies in syphilis. Vener Dis Info Supple. ‘ment 21, US. Public Health Service Venereal Disease Divison, 1917, 2. Olansy 5: Late benign syphilis (gumma). Med Clin North Am 48: 658-666, 1961, ‘3. Kampmeier RH: The late manifestations of syphilis: skeletal, vi ‘eral and cardiovescular. Med Clin North Am 48: 667-697, 1964 4.Clark EG, DanboltN: Oslo study ofthe natural course of untreated ‘philisJ Chron Dis 2: 311-344, 1955. 5. Pembroke AC, Michela PA, Mece PH: Noduosquamous tertiary sxhilde. Clin Ep Dermatol &: 361.364, 1980, 6. St John RK: Treatment of late benign syphilis: review ofthe lit erature. J Am Vener Dis Assoe 3 (pt 2: 146-152, 1976. ‘VOLUME 59, MARCHI007 437