Secondary Syphilis in a Returning Traveler

The image illustrates the cutaneous manifestations and histopathological findings in a 30-year-old returning traveler from the Middle East. He presented with a 10-day history of fever with chills and generalized pleomorphic erythematous skin lesions, including involvement of the palms but without mucosal lesions. He also reported severe bilateral leg pain of the same duration. He denied any history of headache, visual disturbances, night sweats, illicit drug use, or insect bites. He reported no history of sexual contact with men. His medical history was notable for human immunodeficiency virus HIV-1 infection diagnosed 9 months prior, for which he had achieved viral suppression on antiretroviral therapy. At the time of HIV diagnosis, he was also found to have latent syphilis and had received two doses of benzathine penicillin G. He denied any potential re-exposure since initiating treatment. On physical examination, he was found to have multiple erythematous, discrete scaly papules predominantly distributed over the neck, shoulders, trunk, and extremities, including the palms. There was warmth and tenderness over both shins. Examination of the oral, nasal, and anogenital mucosa was unremarkable, and there was no regional lymphadenopathy. Systemic examination was otherwise normal. Laboratory investigations revealed normal blood counts, liver function tests, and urinalysis. Blood cultures were negative. Magnetic resonance imaging of both legs showed only mild bone marrow signal changes. Serologic testing for syphilis showed a reactive screening enzyme-linked immunosorbent assay (3240 RU/mL) and a rapid plasma reagin titer reactive at 1:32 dilutions. Cerebrospinal fluid analysis showed no evidence of neurosyphilis, and ocular involvement was excluded. Histopathological examination of a skin biopsy revealed superficial and deep dermal perivascular and periadnexal granulomatous inflammation. Immunohistochemistry demonstrated the presence of Treponema spirochetes localized to the lower half of the epidermis, superficial dermal vessel walls, and perivascular spaces (Figure 1: as shown in the cover image). The patient reported no new sexual contacts, suggesting that this episode of syphilis likely represented a treatment failure due to previously inadequate management of latent infection. He was subsequently administered a complete course of benzathine penicillin G, to which he showed a marked clinical response, with resolution of fever, leg pain, and cutaneous lesions by the end of therapy. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.