Article Text
PDF
Statistics from Altmetric.com
Description
A 44-year-old man, married, consulted his general practitioner with a 5-day history of fever, myalgia, headache and dry cough. Physical examination demonstrated wheezes in lung auscultation and liver function tests revealed cholestatic hepatitis with no increase in inflammatory markers; abdominal ultrasound was normal and thorax tomography showed small areas of subpleural consolidation (figure 1) and infracentimetric mediastinal lymph nodes suggestive of infection. A hepatotropic viral infection was presumed and he was treated symptomatically with no improvement. He was admitted to the hospital 2 weeks later presenting with perianal condylomata lata and psoriasiform papules affecting the trunk, genitalia, palms and soles (figure 2). Serological markers of hepatitis A, B and C and HIVs were negative and alpha 1-antitrypsin deficiency, autoimmunity and iron or copper overload were excluded. Both serum venereal disease research laboratory (VDRL) and treponemic tests were positive, the former with a titre of 1:128, and dark-field microscopy demonstrated Treponema pallidum in skin lesions. The diagnosis of secondary syphilis was established and T pallidum polypeptide antigens were detected in bronchoalveolar lavage using molecular biology techniques, which confirmed lung involvement. He was treated intramuscularly with a single dose of 2.4 million units IM of benzathine penicillin G. Control examination 1 month later showed a complete regression of symptoms and both skin and lung lesions, as well as liver function normalisation, making the diagnosis of syphilitic hepatitis most likely. He would end up assuming swinging practice and his sexual partners were subsequenly tested and treated accordingly. VDRL titre fell to 1:4 within 12 months.
Thorax CT scan demonstrating small areas of subpleural consolidation.
Palmar psoriasiform papules.
Learning points
Secondary syphilis is a systemic disease that can affect most organs and tissues of the human body; due to the wide ranging variability in clinical presentation, this disease has earned the label ‘the great imitator’.1
With an increasing incidence during the past years,2 diagnosis is often missed or delayed, as the absence of classical features of the disease (such as the secondary syphilis orogenital lesion rash) and increasing number of unusual clinical presentations have been reported.3
A high level of suspicion is required for prompt recognition and management of this easily diagnosed and treatable condition, with therapeutic inertia being highly prejudiciable to the patient.
Footnotes
Contributors All the authors (DMMF, AA, GP and RR) gathered and wrote together this case report description. DMMF was the only responsible for bibliographic research and writing the conclusion for this manuscript. The corresponding author takes full responsibility for the overall content.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.