Report
Pustular secondary syphilis: report of three cases and review of the literature Viktoryia Kazlouskaya1,2, MD, PhD, Christa Wittmann3, MD, and Iryna Tsikhanouskaya4, MD, PhD
1 Ackerman Academy of Dermatopathology, New York, NY, USA, 2Department of Dermatovenereology, Gomel State Medical University, Gomel, Belarus, 3Department of Internal Medicine, Lenox Hill Hospital, New York, NY, USA, and 4Department of Dermatovenereology, Vitebsk State Medical University, Vitebsk, Belarus
Correspondence Viktoryia Kazlouskaya, MD, PHD Ackerman Academy of Dermatopathology 145 East 32nd Street, 10th Floor New York, NY 10016, USA E-mail: [email protected] Funding: None. Conflicts of interest: None.
Abstract Background Pustular syphilis is an extremely rare manifestation of secondary syphilis. Failure to recognize the disease can have devastating consequences. Methods We present three patients with pustular syphilis as the primary manifestation of secondary syphilis. Results Patient 1 was initially diagnosed by Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Patient 2 was screened for syphilis by VDRL (titers 1 : 64), yielding a positive result, and tested negative for HIV. Secondary syphilis was confirmed by EIA. In Patient 3, a diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy in three patients. Testing for HIV infection was negative in all patients. Conclusions Diagnosis in secondary syphilis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other stages of syphilitic infection. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis.
Introduction Pustular syphilis is a known manifestation of secondary syphilis and is thought to be exceedingly rare. Descriptions of the disease are found in a limited number of case reports, most of which come from developing countries.1,2 Failure to recognize the disease can have devastating consequences. Appropriately titled the great masquerader because of its masterful mimicry and variability in presentation, the diagnosis can be missed by those not familiar with pustular variants. We present three patients diagnosed in Belarus with pustular syphilis as the primary manifestation of secondary syphilis.
initially established on the basis of a Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Human immunodeficiency virus (HIV) testing was negative. Skin examination revealed multiple superficial pustules resembling impetigo on the chin and nose. The physical examination was otherwise unremarkable. The patient had assumed the lesions had been caused by a bacterial infection and consequently self-treated with local antiseptics without improvement (Fig. 1). No signs of hard chancre or erosive lesions were detected on the vulva or vagina. The patient stated that the lesions had been present for approximately two months and that her last unprotected sexual contact had occurred about 6–7 months previously. Treponema pallidum was detected in exudate from the lesions by means of
Materials and methods
e428
Patient 1 A 28-year-old single woman was admitted with a new diagnosis of syphilis made during a routine medical visit. The diagnosis was International Journal of Dermatology 2014, 53, e428–e431
dark field microscopy. Because the duration of the disease was unknown, benzyl penicillin was administered at a dose of 1 million units IM for 21 days (on the basis of European guidelines for the treatment of sexually transmitted diseases3); this led to the complete resolution of the skin lesions within seven days. ª 2014 The International Society of Dermatology
Kazlouskaya et al.
Pustular secondary syphilis: case report and review
Report
configuration. These lesions were accompanied by multiple punched out ulcers, measuring 1–5 cm in diameter, with oyster shell-like crusts. A deep erosion with uneven borders and a purulent base was noted on the glans penis. Treponema pallidum was detected by dark field microscopy performed on material from the base of the lesions. The patient reported multiple unprotected sexual contacts but could not recollect the duration of the infection. The patient was screened for syphilis by VDRL (titers 1 : 64), which is typically performed in all patients at their first visit to a hospital in Belarus, yielding a positive result. Testing for HIV infection was negative. The diagnosis of secondary syphilis was confirmed by EIA. Benzyl penicillin was administered as specified in Patient 1, and the remission of skin symptoms was seen within 14 days. The lesions healed with only superficial scarring. Figure 1 Patient 1, a 28-year-old woman, demonstrates
impetigo-like secondary pustular syphilis on the chin and nose
Patient 2 A 24-year-old patient was referred for multiple, disseminated cutaneous pustules, erosions, and crusts that had been present for an indeterminate length of time (Fig. 2). The patient had attempted treatment with a local antiseptic (Fig. 2b). On examination, multiple lesions resembling ecthyma were observed, along with many pustules. The pustules were superficial and filled with yellowish pus and, although they varied in shape, were mostly annular in
(a)
(b)
Patient 3 A 21-year-old man presented with multiple penile lesions. The patient admitted to multiple unprotected sexual contacts in the past two years, the most recent of which had occurred about six months previously. Multiple purulent lesions covered by thick oyster shell-like crusts were found on the penis shaft (Fig. 3). A diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy. Testing for HIV infection was negative. Benzyl penicillin was administered in a similar manner as in Patients 1 and 2. The skin symptoms demonstrated remission within 14 days and went on to heal with superficial scarring and secondary hyperpigmentation.
(c)
Figure 2 Patient 2, a 24-year-old man, exhibits disseminated pustular syphilis showing as (a) ecthymiform syphilis on the shin, (b) multiple superficial pustules and deep lesions on the sole (green antiseptic solution applied by the patient at home) and (c) purulent erosion and multiple pustular lesions on the penis and scrotum ª 2014 The International Society of Dermatology
International Journal of Dermatology 2014, 53, e428–e431
e429
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Report
Pustular secondary syphilis: case report and review
Figure 3 Patient 3, a 21-year-old man, demonstrates multiple pustules with oyster shell-like crusts on the penis shaft in secondary syphilis
Discussion All three of the present patients were diagnosed in various institutions in Belarus over a 2-year period. These patients exhibited pustular lesions resembling those of bacterial infection, but diagnoses of syphilis were confirmed by VDRL, EIA, and dark field examination. The incidence of syphilis infection in Belarus and other postUSSR countries remains high as a result of tumultuous social and economic conditions, and syphilis remains a global health problem with recent resurgences in Europe and the USA. The World Health Organization estimates an incidence of 12 million new cases each year, more than 90% of which occur in the developing world.4 Diagnosis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation in secondary syphilis is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. Pustular lesions are less common and pose an even greater diagnostic challenge. In a study of 105 patients with secondary syphilis, Chapel found pustular lesions in about 1.9% of patients.5 The largest series of patients with pustular syphilis was described by Siddappa and Madvamurthy, who presented 21 cases with a male to female predominance of 2 : 1 collected during four years of observation.6 Pustular lesions more commonly affect individuals with poor health and malnutrition, and co-infection with HIV is frequent.6 An entity variant known as malignant syphilis (lues maligna) often presents in HIV-positive patients infected with T. pallidum and is typically accompanied International Journal of Dermatology 2014, 53, e428–e431
Kazlouskaya et al.
by nonspecific, prodromal symptoms suggesting systemic involvement.7,8 It resembles the original reports of great pox in Europe following the voyages of Christopher Columbus. All of the three patients reported herein were HIV-negative and lacked systemic involvement and a fulminant course of disease; therefore, we consider that they should not be classified as having lues maligna. Pustular syphilis can be divided into four main descriptive subgroups.6,9 Miliary pustular syphilis presents with small, 3–5-mm, perifollicular pustules.10,11 Acuminate syphilis takes two forms: acneiform syphilis usually localizes on the face and presents with papules and papulopustules resembling those of acne vulgaris,12 and varioliform syphilis presents with pustules and central crusts that form punched out even ulcers resembling those in varicella or smallpox infection.13 Flat variants of syphilis include impetiginoid syphilis, which presents with flat pustules and yellowish crusts, and usually occurs on the face, scalp, and intertriginous areas, and ecthymiform syphilis, which presents with lesions measuring up to 5 cm in diameter that form ulcers with an overlying crust.14 Pustulo-ulcerative crusted (rupioid) syphilis presents with pustules and papules that are covered by thick oyster-like crusts. This form of syphilis is often accompanied by systemic involvement.2 According to Siddappa and Madvamurthy, acneiform and varioliform syphilis were the most frequent variants, accounting for 12 of 21 cases.6 In the present group, pustulo-ulcerative lesions were seen in two of three patients and an impetiginoid type in the third. Although this classification nowadays has mostly historical significance, clinical types of secondary pustular syphilis are still seen in populations with low socioeconomic status and should be kept in mind in cases of unusual pyogenic infection. The immunopathogenesis behind the formation of pustules in secondary syphilis is unclear. The majority of cases show no infection by Staphylococcus aureus in the lesion, but cases with staphylococcal infection and Treponema spp. in the lesion have been previously described.11 The presence of numerous spirochetes on dark field examination and the finding that the lesions do not respond unless an appropriate antibiotic regimen directed against T. pallidum is used suggest that they represent specific manifestations of the spirochete. The formation of ulcers and pustules as a result of the syphilitic involvement of small vessels of the skin has been postulated.15 Lesions often evolve from a more typical papular eruption. The variations in clinical presentation may be determined by the balance between delayed-type hypersensitivity and humoral immunity. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other ª 2014 The International Society of Dermatology
Kazlouskaya et al.
stages of syphilitic infection.15 Treponema pallidum may be visualized by means of dark-field microscopy of material from the base of the lesions or by using Warthin–Starry stain or immunostains applied to skin biopsy specimens. Some cases show a paucity of microorganisms that are difficult to visualize.7 Positive results suggest that the lesions represent a specific manifestation of the disease. The typical histological picture of pustular lesions is often characterized by superficial subcorneal pustules and follicular neutrophilic abscesses.15 If present, collections of neutrophils with the stratum corneum, elongated rete ridges with evidence of interface dermatitis, swollen endothelial cells, plasma cells, and lymphocytes with ample cytoplasm help to suggest the diagnosis.15 We hope the present report will draw attention to pustular variants of syphilis. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis. Acknowledgment The authors would like to thank Dirk Elston, director of the Ackerman Academy of Dermatopathology, for his help in the preparation of this manuscript. References 1 Aggarwal K, Gupta S, Jain VK. Pustulocrustaceous secondary syphilis. Acta Derm Venereol 2005; 85: 378– 379.
ª 2014 The International Society of Dermatology
Pustular secondary syphilis: case report and review
Report
2 Bhagwat PV, Tophakhane RS, Rathod RM, et al. Rupioid syphilis in an HIV patient. Indian J Dermatol Venereol Leprol 2009; 75: 201–202. 3 Radcliffe KW. Introduction. European STD guidelines. Int J STD AIDS 2001; 12(Suppl. 3): 2–3. 4 Hook EW III, Peeling RW. Syphilis control – a continuing challenge. N Engl J Med 2004; 351: 122–124. 5 Chapel TA. The signs and symptoms of secondary syphilis. Sex Transm Dis 1980; 7: 161–164. 6 Siddappa K, Madvamurthy P. Pustular secondary syphilis: a study of twenty-one cases. Indian J Sex Transm Dis 1982; 3: 8–12. 7 Pleimes M, Hartschuh W, Kutzner H, et al. Malignant syphilis with ocular involvement and organism-depleted lesions. Clin Infect Dis 2009; 48: 83–85. 8 Wang H, Wang X, Li S. A case of lues maligna in an AIDS patient. Int J STD AIDS 2012; 23: 599–600. 9 Miller RL. Pustular secondary syphilis. Br J Vener Dis 1974; 50: 459–462. 10 Mikhail GR, Chapel TA. Follicular papulopustular syphilid. Arch Dermatol 1969; 100: 471–473. 11 Noppakun N, Dinehart SM, Solomon AR. Pustular secondary syphilis. Int J Dermatol 1987; 26: 112– 114. 12 Lambert WC, Bagley MP, Khan Y, et al. Pustular acneiform secondary syphilis. Cutis 1986; 37: 69–70. 13 Lejman K, Starzycki Z. Early varioliform syphilis. A case report. Br J Vener Dis 1981; 57: 25–29. 14 Zui GI, Mikhailov VN. Case of ecthymiform and rupioid syphilid. Vestn Dermatol Venerol 1981; 10: 67–68. 15 Carlson JA, Dabiri G, Cribier B, et al. The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol 2011; 33: 433–460.
International Journal of Dermatology 2014, 53, e428–e431
e431
Pustular secondary syphilis: report of three cases and review of the literature Viktoryia Kazlouskaya1,2, MD, PhD, Christa Wittmann3, MD, and Iryna Tsikhanouskaya4, MD, PhD
1 Ackerman Academy of Dermatopathology, New York, NY, USA, 2Department of Dermatovenereology, Gomel State Medical University, Gomel, Belarus, 3Department of Internal Medicine, Lenox Hill Hospital, New York, NY, USA, and 4Department of Dermatovenereology, Vitebsk State Medical University, Vitebsk, Belarus
Correspondence Viktoryia Kazlouskaya, MD, PHD Ackerman Academy of Dermatopathology 145 East 32nd Street, 10th Floor New York, NY 10016, USA E-mail: [email protected] Funding: None. Conflicts of interest: None.
Abstract Background Pustular syphilis is an extremely rare manifestation of secondary syphilis. Failure to recognize the disease can have devastating consequences. Methods We present three patients with pustular syphilis as the primary manifestation of secondary syphilis. Results Patient 1 was initially diagnosed by Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Patient 2 was screened for syphilis by VDRL (titers 1 : 64), yielding a positive result, and tested negative for HIV. Secondary syphilis was confirmed by EIA. In Patient 3, a diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy in three patients. Testing for HIV infection was negative in all patients. Conclusions Diagnosis in secondary syphilis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other stages of syphilitic infection. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis.
Introduction Pustular syphilis is a known manifestation of secondary syphilis and is thought to be exceedingly rare. Descriptions of the disease are found in a limited number of case reports, most of which come from developing countries.1,2 Failure to recognize the disease can have devastating consequences. Appropriately titled the great masquerader because of its masterful mimicry and variability in presentation, the diagnosis can be missed by those not familiar with pustular variants. We present three patients diagnosed in Belarus with pustular syphilis as the primary manifestation of secondary syphilis.
initially established on the basis of a Venereal Disease Research Laboratory (VDRL) test (titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Human immunodeficiency virus (HIV) testing was negative. Skin examination revealed multiple superficial pustules resembling impetigo on the chin and nose. The physical examination was otherwise unremarkable. The patient had assumed the lesions had been caused by a bacterial infection and consequently self-treated with local antiseptics without improvement (Fig. 1). No signs of hard chancre or erosive lesions were detected on the vulva or vagina. The patient stated that the lesions had been present for approximately two months and that her last unprotected sexual contact had occurred about 6–7 months previously. Treponema pallidum was detected in exudate from the lesions by means of
Materials and methods
e428
Patient 1 A 28-year-old single woman was admitted with a new diagnosis of syphilis made during a routine medical visit. The diagnosis was International Journal of Dermatology 2014, 53, e428–e431
dark field microscopy. Because the duration of the disease was unknown, benzyl penicillin was administered at a dose of 1 million units IM for 21 days (on the basis of European guidelines for the treatment of sexually transmitted diseases3); this led to the complete resolution of the skin lesions within seven days. ª 2014 The International Society of Dermatology
Kazlouskaya et al.
Pustular secondary syphilis: case report and review
Report
configuration. These lesions were accompanied by multiple punched out ulcers, measuring 1–5 cm in diameter, with oyster shell-like crusts. A deep erosion with uneven borders and a purulent base was noted on the glans penis. Treponema pallidum was detected by dark field microscopy performed on material from the base of the lesions. The patient reported multiple unprotected sexual contacts but could not recollect the duration of the infection. The patient was screened for syphilis by VDRL (titers 1 : 64), which is typically performed in all patients at their first visit to a hospital in Belarus, yielding a positive result. Testing for HIV infection was negative. The diagnosis of secondary syphilis was confirmed by EIA. Benzyl penicillin was administered as specified in Patient 1, and the remission of skin symptoms was seen within 14 days. The lesions healed with only superficial scarring. Figure 1 Patient 1, a 28-year-old woman, demonstrates
impetigo-like secondary pustular syphilis on the chin and nose
Patient 2 A 24-year-old patient was referred for multiple, disseminated cutaneous pustules, erosions, and crusts that had been present for an indeterminate length of time (Fig. 2). The patient had attempted treatment with a local antiseptic (Fig. 2b). On examination, multiple lesions resembling ecthyma were observed, along with many pustules. The pustules were superficial and filled with yellowish pus and, although they varied in shape, were mostly annular in
(a)
(b)
Patient 3 A 21-year-old man presented with multiple penile lesions. The patient admitted to multiple unprotected sexual contacts in the past two years, the most recent of which had occurred about six months previously. Multiple purulent lesions covered by thick oyster shell-like crusts were found on the penis shaft (Fig. 3). A diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA. Treponema pallidum was detected by dark field microscopy. Testing for HIV infection was negative. Benzyl penicillin was administered in a similar manner as in Patients 1 and 2. The skin symptoms demonstrated remission within 14 days and went on to heal with superficial scarring and secondary hyperpigmentation.
(c)
Figure 2 Patient 2, a 24-year-old man, exhibits disseminated pustular syphilis showing as (a) ecthymiform syphilis on the shin, (b) multiple superficial pustules and deep lesions on the sole (green antiseptic solution applied by the patient at home) and (c) purulent erosion and multiple pustular lesions on the penis and scrotum ª 2014 The International Society of Dermatology
International Journal of Dermatology 2014, 53, e428–e431
e429
e430
Report
Pustular secondary syphilis: case report and review
Figure 3 Patient 3, a 21-year-old man, demonstrates multiple pustules with oyster shell-like crusts on the penis shaft in secondary syphilis
Discussion All three of the present patients were diagnosed in various institutions in Belarus over a 2-year period. These patients exhibited pustular lesions resembling those of bacterial infection, but diagnoses of syphilis were confirmed by VDRL, EIA, and dark field examination. The incidence of syphilis infection in Belarus and other postUSSR countries remains high as a result of tumultuous social and economic conditions, and syphilis remains a global health problem with recent resurgences in Europe and the USA. The World Health Organization estimates an incidence of 12 million new cases each year, more than 90% of which occur in the developing world.4 Diagnosis remains challenging because of the diversity of clinical presentations. The most commonly observed cutaneous presentation in secondary syphilis is a generalized, non-pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous membrane involvement. Pustular lesions are less common and pose an even greater diagnostic challenge. In a study of 105 patients with secondary syphilis, Chapel found pustular lesions in about 1.9% of patients.5 The largest series of patients with pustular syphilis was described by Siddappa and Madvamurthy, who presented 21 cases with a male to female predominance of 2 : 1 collected during four years of observation.6 Pustular lesions more commonly affect individuals with poor health and malnutrition, and co-infection with HIV is frequent.6 An entity variant known as malignant syphilis (lues maligna) often presents in HIV-positive patients infected with T. pallidum and is typically accompanied International Journal of Dermatology 2014, 53, e428–e431
Kazlouskaya et al.
by nonspecific, prodromal symptoms suggesting systemic involvement.7,8 It resembles the original reports of great pox in Europe following the voyages of Christopher Columbus. All of the three patients reported herein were HIV-negative and lacked systemic involvement and a fulminant course of disease; therefore, we consider that they should not be classified as having lues maligna. Pustular syphilis can be divided into four main descriptive subgroups.6,9 Miliary pustular syphilis presents with small, 3–5-mm, perifollicular pustules.10,11 Acuminate syphilis takes two forms: acneiform syphilis usually localizes on the face and presents with papules and papulopustules resembling those of acne vulgaris,12 and varioliform syphilis presents with pustules and central crusts that form punched out even ulcers resembling those in varicella or smallpox infection.13 Flat variants of syphilis include impetiginoid syphilis, which presents with flat pustules and yellowish crusts, and usually occurs on the face, scalp, and intertriginous areas, and ecthymiform syphilis, which presents with lesions measuring up to 5 cm in diameter that form ulcers with an overlying crust.14 Pustulo-ulcerative crusted (rupioid) syphilis presents with pustules and papules that are covered by thick oyster-like crusts. This form of syphilis is often accompanied by systemic involvement.2 According to Siddappa and Madvamurthy, acneiform and varioliform syphilis were the most frequent variants, accounting for 12 of 21 cases.6 In the present group, pustulo-ulcerative lesions were seen in two of three patients and an impetiginoid type in the third. Although this classification nowadays has mostly historical significance, clinical types of secondary pustular syphilis are still seen in populations with low socioeconomic status and should be kept in mind in cases of unusual pyogenic infection. The immunopathogenesis behind the formation of pustules in secondary syphilis is unclear. The majority of cases show no infection by Staphylococcus aureus in the lesion, but cases with staphylococcal infection and Treponema spp. in the lesion have been previously described.11 The presence of numerous spirochetes on dark field examination and the finding that the lesions do not respond unless an appropriate antibiotic regimen directed against T. pallidum is used suggest that they represent specific manifestations of the spirochete. The formation of ulcers and pustules as a result of the syphilitic involvement of small vessels of the skin has been postulated.15 Lesions often evolve from a more typical papular eruption. The variations in clinical presentation may be determined by the balance between delayed-type hypersensitivity and humoral immunity. The diagnostic methods used to identify secondary syphilis are the same as those used to diagnose other ª 2014 The International Society of Dermatology
Kazlouskaya et al.
stages of syphilitic infection.15 Treponema pallidum may be visualized by means of dark-field microscopy of material from the base of the lesions or by using Warthin–Starry stain or immunostains applied to skin biopsy specimens. Some cases show a paucity of microorganisms that are difficult to visualize.7 Positive results suggest that the lesions represent a specific manifestation of the disease. The typical histological picture of pustular lesions is often characterized by superficial subcorneal pustules and follicular neutrophilic abscesses.15 If present, collections of neutrophils with the stratum corneum, elongated rete ridges with evidence of interface dermatitis, swollen endothelial cells, plasma cells, and lymphocytes with ample cytoplasm help to suggest the diagnosis.15 We hope the present report will draw attention to pustular variants of syphilis. The persistence of syphilis in both developed and underdeveloped regions highlights the importance of considering syphilitic infection in the setting of a cutaneous pustular eruption, especially one that fails to respond to standard therapy. Testing for other sexually transmitted diseases, including HIV, should be performed in all patients diagnosed with syphilis. Acknowledgment The authors would like to thank Dirk Elston, director of the Ackerman Academy of Dermatopathology, for his help in the preparation of this manuscript. References 1 Aggarwal K, Gupta S, Jain VK. Pustulocrustaceous secondary syphilis. Acta Derm Venereol 2005; 85: 378– 379.
ª 2014 The International Society of Dermatology
Pustular secondary syphilis: case report and review
Report
2 Bhagwat PV, Tophakhane RS, Rathod RM, et al. Rupioid syphilis in an HIV patient. Indian J Dermatol Venereol Leprol 2009; 75: 201–202. 3 Radcliffe KW. Introduction. European STD guidelines. Int J STD AIDS 2001; 12(Suppl. 3): 2–3. 4 Hook EW III, Peeling RW. Syphilis control – a continuing challenge. N Engl J Med 2004; 351: 122–124. 5 Chapel TA. The signs and symptoms of secondary syphilis. Sex Transm Dis 1980; 7: 161–164. 6 Siddappa K, Madvamurthy P. Pustular secondary syphilis: a study of twenty-one cases. Indian J Sex Transm Dis 1982; 3: 8–12. 7 Pleimes M, Hartschuh W, Kutzner H, et al. Malignant syphilis with ocular involvement and organism-depleted lesions. Clin Infect Dis 2009; 48: 83–85. 8 Wang H, Wang X, Li S. A case of lues maligna in an AIDS patient. Int J STD AIDS 2012; 23: 599–600. 9 Miller RL. Pustular secondary syphilis. Br J Vener Dis 1974; 50: 459–462. 10 Mikhail GR, Chapel TA. Follicular papulopustular syphilid. Arch Dermatol 1969; 100: 471–473. 11 Noppakun N, Dinehart SM, Solomon AR. Pustular secondary syphilis. Int J Dermatol 1987; 26: 112– 114. 12 Lambert WC, Bagley MP, Khan Y, et al. Pustular acneiform secondary syphilis. Cutis 1986; 37: 69–70. 13 Lejman K, Starzycki Z. Early varioliform syphilis. A case report. Br J Vener Dis 1981; 57: 25–29. 14 Zui GI, Mikhailov VN. Case of ecthymiform and rupioid syphilid. Vestn Dermatol Venerol 1981; 10: 67–68. 15 Carlson JA, Dabiri G, Cribier B, et al. The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol 2011; 33: 433–460.
International Journal of Dermatology 2014, 53, e428–e431
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