Summary : A 20-year-old male soldier presented with a diffuse skin eruption that had started three weeks previously with the development of erythematous lesions scattered over the trunk and limbs. The diagnosis of varicella was initially suggested by a general practitioner and the patient was kept under surveillance. However the lesions progressively spread. The patient was referred to a dermatologist who suggested the diagnosis of psoriasis guttata and referred the patient to the Dermatology Department of the 424 General Military Hospital of Thessaloniki (Greece). Physical examination revealed a diffuse eruption made up of several hundred erythematous, copper-colored, slightly infiltrated, scaly papules (Figs. 1 and 2) some of which were surrounded by a scaly collarette (Fig. 3). They predominated on the trunk (chest and abdomen), the back, the anterior aspect of the upper limbs and the legs. Scattered lesions were found on the chin, the neck, the palms and soles, the penis shaft and the scrotum. The papules were usually discrete but occasionally coalesced to form small psoriasiform plaques. The lesions were asymptomatic but the patient complained of fatigue. The hair and nails were not affected, and no mucous lesions were found. There was moderate, firm swelling of axillary and inguinal lymph nodes. Family and personal history were unremarkable. |
ARTICLE
Diffuse psoriasiform eruption in a young adult
Secondary syphilis
Serological tests (Wassermann-Kahn) proved positive for recent infection
with Treponema pallidum. The patient reported sexual intercourse
with a prostitute about two months before the onset of the eruption but
could not recall the appearance of a chancre. He was treated with daily
intramuscular injections of penicillin G (2.4 MU/d). The lesions regressed
slowly within one month, leaving a residual pigmentation.
Cutaneous lesions of secondary syphilis (syphilids) are seen in 80-95%
of patients with secondary syphilis and develop 2-3 months after contamination
with Treponema pallidum. They are highly polymorphic in appearance
(macular, maculopapular, papulosquamous, follicular, lenticular, corymbose,
nodular, annular, pustular) and may mimic almost any dermatosis. Our patient
presented with papulosquamous lesions that mimicked psoriasis guttata.
However on closer examination the lesions were infiltrated; they occasionnally
had a copper hue and some of them were surrounded by an epidermal collarette
(Biette's collarette), all features differentiating syphilids from psoriasis.
The definite diagnosis was made through serological tests, showing a recent,
active infection. The lesions were very profuse and could suggest an immune
deficiency. Although HIV serology was unavailable at the time the patient
was seen, no clinical signs of immunodeficiency were recorded. The profusion
of the lesions was likely to be due to the delay in diagnosis and treatment.
"Syphilis simulates every other disease. It is the only disease necessary
to know. One then becomes an expert dermatologist, an expert laryngologist,
an expert oculist, an expert internist and an expert diagnostician" (Sir
William Osler).
Article accepted on 25/1/01
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