Secondary syphilis presenting in a red tattoo

ARTICLE

Auteur(s) : Jing Yuan¹, Weiyun Li¹, Zhenshan Xia², Shi-Jun Shan³, Ying Guo⁴, Hong-Duo Chen⁵

¹Department of Dermatology, Tianjin Changzheng Hospital, Tianjin, China
²Department of Urology, Tianjin Medical University General Hospital, Tianjin, China
³Department of Dermatology, Tianjin Medical University General Hospital, No.154 Anshan Road, Tianjin, 300052, China.
⁴Ackerman Academy of Dermatopathology, New York, New York
⁵Department of Dermatology, No.1 Hospital of China Medical University, Shenyang, China.

A 26-year-old Chinese male presented with a reddish brown scaly maculopapular eruption on a red tattoo on his trunk, and with slight pruritus for about 6 months. The initial lesions occurred on his palms. The red area of the tattoo was involved although the dark blue area of the tattoo was free of lesions. One year before, the patient had a dragon tattooed on his trunk with bulk dark ink and a few cinnabars, by a professional tattoo artist. He had a history of unprotected sexual activities during the previous 12 months. No history of genital ulcer or other cutaneous or systemic disease could be elicited from the patient. There was no history of hair loss.

Physical examination revealed reddish brown macules and papules with slight scales, which covered most of the red area of the tattoo. The dark blue area was not involved (figure 1A). A scaly circular rash was present on his palms. There was no palpable lymphadenopathy. Mucous membranes of the mouth and pharynx were unremarkable. A biopsy from the lesion on the red tattoo revealed parakeratosis, acanthosis and numerous neutrophils present within the epidermis; a diffused infiltrate of plasma cells associated with red and black pigment-containing macrophages was present in the upper dermis (figure 1B). Warthin-Starry staining was performed and was negative for spirocheta. Laboratory tests including blood, urine, stools, hepatic and renal functions were all within normal limits. A patch test for cinnabar was negative. Repeated fungal tests under microscopy and cultures were negative. The result of rapid plasma reagin (RPR) was positive with titre 1:32. Treponema pallidum hemagglutination assay (TPHA) exhibited a positive result with titre 1:2560. HIV antibody was negative. A diagnosis of secondary syphilis was made. Procaine benzylpenicillin was prescribed, 800,000 units per day for 2 weeks. Lesions of the trunk and palms cleared completely about 4 weeks later. The RPR titre decreased to 1:2.

Syphilis is a chronic sexually transmitted disease caused by Treponema pallidum. Its incidence has risen in the last few decades [1]. Up to now, the relationship between tattoos and syphilis is uncertain. It was believed that the needles used during tattooing and the saliva used to dilute the dye were the main routes of transmission of the disease. However, some considered that to be just coincidence [2, 3].

In our patient, the macular lesions initially occurred on the palms, followed by a reddish brown rash limited to the red tattoo. To our knowledge, this has not been reported previously in the English literature. It has been documented that, in syphilis, the lesions concentrate in dark blue dye areas and spare the red ones [4-6]. It was considered that red mercuric sulfide could inhibit Treponema pallidum in the early period of syphilis. In our case, lesions were confined to the red area of the tattoo; the mechanism of this phenomenon is uncertain. Further studies are needed to elucidate the mechanism of the action.

Acknowledgments

References

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4 Goldman L. Macular syphilides absent in red tattoo. Cutis 1989; 44: 313.

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6 Lipschutz E. Verhandlungen der Wiener dermatologischen Gesellschaft. Arch Dermatol 1906; 78: 381-5.