Psoriasiform lesions of glans and palms: A rare presentation in secondary syphilis.

Erythematous scaly papules on the palms and soles are a common manifestation of secondary syphilis. We report a case of 19-year-old male who presented with erythematous, scaly, psoriasiform lesions over the palms and glans penis. The papules over the palms showed tenderness on blunt vertical pressure. There was a history of sexual contact and ulcer over the glans around 2 months back, which resolved on its own. Venereal Disease Research Laboratory test was positive in 1:32 dilution. Treponema pallidum hemagglutination test was also positive. This case highlights the atypical presentation of secondary syphilis.

INTRODUCTION

Syphilis is a chronic sexually acquired systemic infection caused by a spirochaete Treponema pallidum subsp. pallidum.[1] The disease has an early infectious stage and a late noninfectious phase. Early syphilis consists of primary syphilis, secondary syphilis, and early latent syphilis. The secondary syphilis is referred to as “the great imitator” as it may present with varied presentations. We present a case of secondary syphilis with psoriasiform lesions over the glans and palms.

CASE REPORT

A 19-year-old male presented to us with redness and scaling over the palms and glans penis for 1 month. The lesions were largely asymptomatic with occasional low-intensity itching over the glans. The patient gave a history of a single heterosexual contact with a commercial sex worker around 3 months back. Around 25 days after this contact, the patient developed an ulcer over the penis that was painless and hard and subsided after a month on its own. The patient took no oral medications for the same but had applied some topical ointment purchased over the counter. He also gave a history of sore throat for 15 days. There were no other complaints.

On examination, multiple, discrete, 3–5 mm erythematous, scaly, psoriasiform papuloplaques were present over the palms [Figure 1]. Vertical pressure over the lesions caused pain. The glans penis showed ill-defined psoriasiform plaques with peripheral collarette of scales [Figure 2]. There was no scarring at the site where the patient complained of the ulcer. Pharynx was congested. Rest of the cutaneous and mucosal examination was normal. There was no lymphadenopathy. Systemic examination was normal.

Figure 1

Psoriasiform papules and plaques over the palms

Figure 2

Ill-defined psoriasiform plaques over the glans penis with peripheral collarette of scales

Laboratory investigations

A Venereal Disease Research Laboratory (VDRL) test was ordered and showed positivity in 1:32 titer. A voluntary HIV enzyme-linked immunosorbent assay was ordered and was found to be nonreactive. A confirmatory Treponema pallidum hemagglutination test was advised and was found to be positive. A skin biopsy from the lesion over the palm was done and it showed hyperkeratosis, parakeratosis, acanthosis, and a lymphohistiocytic infiltrate with plasma cells in the dermis concentrated mainly in the periadnexal areas [Figure 3a and b]. Based on the typical history, clinical examination, laboratory investigations, and further supported by histopathological findings, a diagnosis of secondary syphilis was made. The patient was treated with injection benzathine penicillin 2.4 million IU in the buttocks after prior test dose. He was also counseled for safe sexual practices and use of barriers. He is being followed up and advised for posttreatment VDRL and HIV ELISA tests.

Figure 3

(a) Psoriasiform hyperplasia and acanthosis of the epidermis (H and E, ×10) and (b) there is dense perivascular as well as diffuse lymphoplasmacytic infiltrate within the superficial dermis (H and E, ×40)

DISCUSSION

Syphilis was a common sexually acquired infection during the second world war, but the incidence of the disease declined until the emergence of HIV/AIDS. HIV and syphilis are both acquired sexually and facilitate transmission of each other.[2] Recent studies indicate that the number of syphilis cases has shown an increase after it reached a nadir at the turn of the millennium.[3] After an incubation period of 9–90 days, a primary chancre forms at the site of inoculation that heals in 2–6 weeks and secondary syphilis arises. A depressed scar at the site of chancre is present in only a tenth of all cases. Cutaneous lesions are the most common manifestation of secondary syphilis and are seen in 72% of individuals.[4] Involvement of the palms and soles with erythematous papules and a collarette of scales is quite common. Lesions may present as psoriasiform when the scaling is more intense.[5] However, we could not find any case report with psoriasis-like lesions over the glans penis. The elicitation of tenderness on the application of blunt pressure over a syphilitic papule is considered as a pathognomonic sign of syphilis and is called the Buschke–Ollendorff sign.[1] Other common cutaneous manifestations seen in secondary syphilis include macular, papular, nodular, lichenoid, annular, pustular, and follicular lesions.[6] The rash of syphilis is characteristically more prominent over the upper extremities and is bilaterally symmetrical. Oropharyngeal manifestations range from asymptomatic inflammation to severe pharyngitis. Lymphadenopathy is seen in 60%–100% cases.[1]

CONCLUSION

Our case presented with psoriasiform lesions over the palms, a common manifestation of secondary syphilis and a characteristic history. The presence of psoriasiform lesions over the glans is an uncommon finding. We present this case to highlight that syphilis is down but not out and it must be kept in mind when dealing with atypical presentation of any disease.

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.