Background
Since 2000 the incidence of syphilis in the United States has increased by over 400%. Classically, secondary syphilis presents as a generalized, non-pruritic, maculopapular rash, often including the palms and soles. However, due to the wide range of mucocutaneous presentations, secondary syphilis is often called ‘The Great Imitator.’ Herein, we report an unusual presentation of secondary syphilis to remind physicians to consider this diagnosis. 

Case Presentation
A 39-year-old female with a history of Hepatitis B presented with a two-month history of numerous tender, crusted, erythematous papules on the face and neck, as well as superficial ulcerations on the tongue, posterior oropharynx, and lower mucosal lip. The lesions first appeared around her nose and mouth after wearing a new cloth mask and then spread more broadly across her face and neck. She had previously been treated with courses of acyclovir and methylprednisolone with no improvement. A seven-day course of sulfamethoxazole-trimethoprim 800mg-160mg resulted in partial healing of some of the lesions. She also endorsed hoarseness and a sore throat but denied additional systemic symptoms, sick contacts, or recent travel. Our differential diagnoses included: sarcoidosis, deep fungal infection, bullous impetigo, Majocchi's granuloma, cutaneous tuberculosis, cutaneous lymphoma, and lupus.
Punch biopsies revealed superficial and deep dense lymphoplasmacytic infiltrate with spirochetes seen in the epidermis on H&E. The rapid plasma reagin titer was reactive (1:4), and anti-Treponema pallidum IgG was positive, confirming the diagnosis of secondary syphilis. The patient was treated with an intramuscular injection of Penicillin G benzathine resulting in complete resolution of the lesions.

Discussion
The incidence of syphilis infection has been increasing in the United States in recent years. The case described herein demonstrates the importance of including secondary syphilis, an infection that often masquerades as others, in the differential when sexually active patients present with mucocutaneous lesions. Rapid identification is essential to combat this increasingly prevalent infection in the United States, through expeditious treatment and effective contact tracing. 


The Great Imitator: an unusual presentation of secondary syphilis

Clinical Vignettes | Dermatology

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