The Great Imitator:Atypical Cutaneous Manifestations of Primary Syphilitic Chancre

Objective To analyze the reasons of misdiagnosis of primary syphilitic chancre and strengthen the understanding of atypical features of this disease.Methods A case series of twenty-seven challenging primary syphilis patients who were not immediately recognized as chancre was included in our study.The clinical data including the patients’age,sex,skin lesions,HIV status,syphilis serologic test results,treatment,and follow-up results were collected.Hematoxylin-eosin and immunohistochemistry staining of skin biopsy sections were reviewed.Results Four female cases with extragenital chancres presenting as erythema or erosive skin lesions on the nipple were misdiagnosed as Paget’s disease or eczema.The disorder of missed or misdiagnosed male cases manifested as syphilitic balanitis or multiple chancres on the penis root and adjacent pubis rather than coronal sulcus or frenum.Patients with nonreactive nontreponemal tests at initial presentation were also easily missed or misdiagnosed.Conclusion Primary syphilis presenting as multiple lesions rather than a single chancre,at atypical locations,or with a nonreactive nontreponemal test result,tends to be missed or misdiagnosed.

Observation of the Ultrastructure in Syphilitic Chancres

Objective: To study the occurrence and development ofprimary syphilis from a morphological and structural aspect.Method: The ultrastructural pathological changes of syphiliticchancre were examined by transmission electron microscopy(TEM). Results: The pathological changes of syphilitic chancreoccur mainly in the dermal layer, manifested as partialthinning or lysis of the capillary basal membrane,proliferation of capillary endothelial cells, thickening of somecollagen fibers and rupture of collagen fibers surrounding Tpallidum, structural disruption of the axons of terminal nerves,disarrangement of the sheath of the myelinated nerve fiberswith separation of laminae and the attachment of T pallidumon its outer membrane, appearance of slightly swollen Tpallidum in the plasma of the capillary endothelial cells andfibroblasts, and infiltration of neutrophils, macrophages andplasma cells containing T pallidum and its debris frequentlylined by a clear sheath. Conclusion: The pathogenesis and injury of mechanism inprimary syphilis can be explained morphologically by itscharacteristic ultrastructural pathological changes.

Early Syphilis Presenting as Thickened Penile Plaques With an Embedded Recurrent Ulcer (Chancre Redux): A Case Report

Introduction:The manifestations of syphilis are varied,and serology can establish the diagnosis early,especially in rare cases.We report a case of chancre redux(a rare recurrence of primary syphilis),which was embedded within a secondary syphilitic penile skin plaque.There were missed opportunities at earlier diagnosis as serology for syphilis was not ordered.Case presentation:A 56-year-old man presented with thickened penile plaques for five months.He reported a small penile ulcer approximately one month prior.There was no history of other skin lesions or rash.However,clinically there was an asymptomatic,indurated ulcer embedded within a plaque which was swab-positive for syphilis by PCR.A punch biopsy of a plaque was spirochaete-positive using an immunoperoxidase stain.The patient’s lesions resolved three weeks after treatment with intramuscular benzathine penicillin.Discussion:Uncommonly reported even in the preantibiotic era,chancre redux is now rare.The ulcer usually recurs at or near the site of the original chancre,and has similar morphological features.The skin lesions of secondary syphilis can exhibit remarkable morphological variety.The most common skin manifestation,a generalized macular rash,was not present at any time in this case.Rather,there were only a couple of nonspecific penile plaques.If biopsy is performed,histologic findings are variable,though typically the inflammatory infiltrate includes plasma cells.A special immunoperoxidase stain can highlight spirochaetes in biopsy sections.Conclusion:This case highlights the importance of considering syphilis in the differential diagnosis of persistent,atypical penile lesions and underscores the need for appropriate serological testing in such instances.

Infectious Disease Update in Obstetrics: A Modern Approach to the Patient with a Positive Screening Test for Syphyilis in Pregnancy

Screening for maternal syphilis has been an essential component of routine antenatal screening tests in most countries for many years. This is not only because of the virulence of the spirochete which causes the infection but also because of its vertical transmission rate and the potential severe adverse complications/morbidity that can result from its transmission to the fetus. Although the incidence of maternal syphilis and its fetal sequalae in low-income countries has been considerable for several years, the disease has been almost non-existent in high income countries with wide antenatal screening coverage and effective treatment programmes for Syphilis. The recent alarming increase in the incidence of maternal syphilis in high income countries has spawned a renewed public health interest in the infection, with several countries updating and strengthening public health guidance in an attempt to stem this dramatic trend. This is a short clinical update for the practising obstetrician on how to manage the antenatal patient with a positive syphilis screening test.