Cluster of Flowers - The Unseen of Syphilis.

Acquired syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum, subspecies pallidum. The disease has been coined “the great imitator” due to its great variability of presentation and mimicry of other conditions.[1] We report the case of a male patient in whom secondary syphilis presented with an exceedingly rare but characteristic pattern of presentation: a corymbiform (or corymbose) syphilide.

A 46-year-old man, presented with 8-day history of high-grade fever with chills and fatigue. He had asymptomatic reddish lesions on upper limbs and trunk. Patient was unmarried with history of sexual exposure with an unknown contact few months ago. Clinical examination revealed four erythematous nodules with surrounding satellite papules resembling corymbose lesion [Figures 1-3]. Buschke ollendroff sign (B O sign) was found to be strongly positive. Mucosa, lymph nodes, and systemic examination were normal. VDRL titers was >1:64. Biopsy revealed aggregates of lymphocytes with few epithelioid cells and plasma cells around the blood vessels in the dermis. Biopsy was reported as chronic granulomatous dermatitis suggestive of secondary syphilis. [Figures 4 and 5]. He was given Benzathine penicillin G 2.4 million units IM in two divided doses on each buttock. At 2 weeks follow-up, patient was relieved of systemic and cutaneous symptoms with reduction of VDRL titers (1:16) [Figure 6a and b].

Figure 1

Corymbose lesions over back and discrete erythematous papules

Figure 3

Cluster of flowers

Figure 4

Aggregates of lymphocytes with few epithelioid cells (H and E – 4×)

Figure 5

Higher magnification of infiltrates, plasma cells around the blood vessels (H and E – 10×)

Figure 6

(a and b) Corymbose lesions showing a resolution post treatment

Erythematous nodule with surrounding satellite papules

Natural history of syphilis is well known, if not treated it goes through four stages: primary, secondary, latent, and tertiary. Especially during the secondary period, it can present with atypical manifestations or with typical manifestations that are infrequent. Dermatological manifestations of the secondary stage are diverse, with reports of macular, papular, nodular, and lichenoid lesions, among others. Presentation of secondary syphilis with corymbiform lesions is extremely rare. Corymbose syphilis is a historical term derived from the Greek, describing a cluster of fruit or flowers; it reflects morphologic characteristics consisting of a central plaque surrounded by discrete papules along the periphery, resembling an explosion.[2]

In the early twentieth century Adamson reported that corymbose syphilis was a well-known though somewhat rare type of syphilide. After many years, Fournier considered syphilide papuleuse en corymbe a rare and bizarre presentation of secondary syphilis that was “very significant due to its singularity”. Finally, Baughn and Musher stated that no other dermatologic disease causes this type of lesion. Corymbose may present as single or several corymbiform arrangements. It was suggested that lesions are an indication of late presentations of secondary syphilis.[1]

Differential diagnosis may include sarcoidosis, amyloidosis, and Sweet's syndrome. A literature search on corymbiform syphilis yields only four results in the last 40 years, showing the rarity of this clinical presentation. Although it is rare, it behaves like other forms of secondary disease, with lesions spread throughout the body.[3]

To summarize, any patient presenting with unexplained cutaneous rash should be investigated for syphilis. Positivity of B O sign highlights the importance of clinical examination in such cases. Failure to recognize and treat syphilitic lesions may have serious consequences. Lesions may undergo spontaneous remission, or enter into a latent stage, and life-threatening complications may eventually ensue. Therefore, a skilled clinician shall constantly exercise a heightened awareness of the different presentations of syphilis.[1]

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