Tertiary syphilis
Authors: Pereira Teresa M. , Fernandes José Carlos , Vieira Ana Paula , Basto A. Sousa 
Published: November 2007

Case 1  A 42‐year‐old married man reported heterosexual behavior with multiple partners, chronic alcoholism, and a previous history of urethritis. He presented with a 1‐year history of two asymptomatic, erythematous to violaceous, annular or polycyclic plaques, involving the anterior aspect of the left thigh. The lesions had raised, well‐defined, infiltrated borders, with irregular crusted ulcers at the periphery, and there was central healing with atrophy (Fig. 1). Histologic examination of a skin biopsy specimen showed lymphocytes and plasma cells infiltrating the superficial and deep dermis, and epithelioid granulomas. Warthin–Starry stain for spirochetes was negative. Venereal Disease Research Laboratory (VDRL) test was reactive (1 : 64) and Treponema pallidum hemagglutination assay (TPHA) was positive. Tests for hepatitis B, hepatitis C, human immunodeficiency virus‐1 (HIV‐1), and HIV‐2 were negative. Neurologic examination revealed changes attributable to chronic alcoholism. VDRL test and TPHA of cerebrospinal fluid were negative. Echocardiogram showed moderate dilatation of the ascending aorta, thickening of the aortic valves, and moderate aortic insufficiency. The patient received 2.4 million units of benzathine penicillin G, intramuscularly, once per week for three consecutive weeks, with rapid resolution of the lesions. His wife had a nonreactive VDRL test and positive TPHA, and was treated with the same regimen.Erythematous to violaceous plaque, with crusted and ulcerated border, on the left thighimageCase 2  A 32‐year‐old married woman of rural background and residence presented with a 1‐year history of occasionally pruritic, papulonodular lesions, involving the presternal (Fig. 2) and left eyebrow (Fig. 3) regions, papules in a polycyclic configuration, and clusters of erythematous, infiltrated nodules, some of which showed ulceration with a surface crust. There was central atrophy and noncontractile scarring. Her husband had been treated for primary syphilis approximately 5 years earlier with benzathine penicillin G; however, the wife was not notified and therefore was not treated. Histologic examination of a presternal lesion revealed erosion and acanthosis with irregular papillomatosis of the epidermis, a dense superficial dermal infiltrate of lymphocytes, plasma cells, and epithelioid cells, and granulomas with multinucleated giant cells. Warthin–Starry stain was negative. VDRL test was reactive (1 : 128) and TPHA was positive. Serology for hepatitis B and C and for HIV‐1 and HIV‐2 was negative. VDRL and TPHA analyses of the cerebrospinal fluid were negative. The patient was treated with 2.4 million units of benzathine penicillin G, intramuscularly, once per week for 3 weeks, with rapid resolution of the lesions. One year after treatment, there was slight central, noncontractile atrophy and peripheral hyperpigmentation (Fig. 4).Clustered, infiltrated nodules, with crusted surfaces and central atrophic scarring, in the presternal regionimageInfiltrated nodules with crusted surfaces on the left eyebrowimagePresternal lesions, 1 year after treatmentimageCase 3  Accompanied by a social worker, this single, mentally retarded, indigent 42‐year‐old man presented with a greater than 1‐year history of two fetid, erythematous to violaceous, exudative plaques with ulcerated bases and circinate, ulcerated borders, involving the inner aspects of both thighs (Fig. 5). Histologic examination showed marked pseudoepitheliomatous hyperplasia of the epidermis and marked inflammation of the papillary and reticular dermis, mainly with plasma cells (Fig. 6). Warthin–Starry stain was negative. VDRL test was reactive (1 : 8) and TPHA was positive. Serologic tests for hepatitis B and C and for HIV‐1 and HIV‐2 were negative. Neurologic examination revealed profound memory impairment and abnormal balance. Computed tomography scan of the head and evaluation of the cerebrospinal fluid were unremarkable. The patient was treated with three intramuscular injections of benzathine penicillin G, 2.4 million units, over three consecutive weeks. The lesions responded rapidly to treatment, with evolution to peripheral hyperpigmentation and central, noncontractile atrophy.Ulcerated plaques involving the inner aspect of both thighsimageInflammatory infiltrate with predominance of plasma cells (hematoxylin and eosin, ×1000)image