Sir,
Syphilis can manifest in protean forms. Cutaneous lesions, though the most common manifestation of secondary syphilis can present in many atypical and/or isolated forms.
A 34-year-old male was referred to the dermatology department to rule out any sexually transmitted infections in view of his steroid-resistant uveitis. The patient had earlier presented to the ophthalmology department with eye redness, photophobia, and progressive diminution of vision in both eyes over a period of 6–8 weeks. Ophthalmological evaluation revealed conjunctival congestion, decreased visual acuity (finger counting at 2 and 1 m in the left and right eye respectively), normal depth of the anterior chamber and a clear lens. Both the pupils were normal in diameter and reacted well to light. Fundoscopic examination demonstrated chorioretinitis [Figure 1].
Figure 1.
Left eye fundoscopic image depicting multifocal chorioretinitis in posterior pole and mid periphery
The patient denied any associated skin, genitourinary or systemic complaints. Cutaneous examination revealed unremarkable skin and mucosa (penile as well as anal) without significant lymphadenopathy. However, bilateral soles showed hyperkeratotic plaques with a marginal collarette of scales [Figure 2a].
Figure 2.
(a) Hyperkeratotic plaques over the soles with collarette of scales, at presentation. (b) Lesions 5 weeks after treatment
Considering a differential diagnosis of Reiter's disease and secondary syphilis we investigated the patient. Serological investigations revealed a positive Venereal Disease Research Laboratroy (VDRL) test with a titer of 1:64 and a positive treponema pallidum hemagglutination test. Serology for HIV was nonreactive. A skin biopsy from the sole showed a psoriasiform hyperplasia of the epidermis with hyperkeratosis, acanthosis, papillomatosis, and a moderate amount of spongiosis. The dermis showed focal and perivascular inflammatory infiltrate comprising of lymphocytes and plasma cells with prominent endothelial inflammation. At places, obvious obliteration of the vascular lumina was noted [Figure 3].
Figure 3.
Biopsy from the sole showing psoriasiform hyperplasia of the epidermis with hyperkeratosis, acanthosis, papillomatosis and a moderate amount of spongiosis, focal and perivascular inflammatory infiltrate comprising of lymphocytes and plasma cells in the dermis
A final diagnosis of secondary syphilis with uveitis was concluded. On probing, the patient revealed his homosexuality and gave a history of unprotected anal intercourse with a partner while on a vacation about 3–4 years ago. However, there was no history of a genital ulcer, generalized rash over the body or any hair loss. Systemic evaluation namely cerebrospinal fluid study, abdominal ultrasound, two-dimensional echocardiography, and magnetic resonance imaging of the orbit and brain were within normal limits.
The patient was started on intravenous benzylpenicillin G 4 million units 4th hourly for 14 days followed by 3 weekly intramuscular injections of benzathine penicillin G 2.4 million units along with topical steroidal eye drops. Over a period of 5 weeks, the patient's skin lesions showed dramatic resolution [Figure 2b] with significant improvement in the visual acuity which improved to 6/18 in both eyes. His latest serology at 5 weeks showed VDRL of 1:32 and is advised to follow-up with repeat tests after 6 months of treatment.
There have been a few citings in the literature associating syphilitic palmoplantar involvement with uveitis.[1,2,3,4] It may be noted that most of these associations were in HIV-positive patients except for the case reported by Hwang et al.[5] In all of these cases, there was concurrent involvement of the palmoplantar surfaces. However, it is important to be aware that sometimes the patient can have totally asymptomatic and isolated palmar or plantar involvement like in our patient, with no telltale signs of infection either on palms or skin or mucosa. Furthermore, the rare combination of plantar keratoderma with ocular syphilis in an HIV-negative individual has not been documented in India.
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References
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