P6829

P6286

Secondary syphilis with exuberant manifestations

Esther Xavier de Brito, MD, Hospital Universit
ario Antonio Pedro, Niteroi, Brazil;
Antonio Sergio Diniz, MD, Hospital Universit
ario Antonio Pedro, Niteroi, Brazil;
Cristiane Cassab Sasajima, MD, Hospital Universit
ario Antonio Pedro, Niteroi,
Brazil; Mayra Rochael, MD, Hospital Universit
ario Antonio Pedro, Niteroi, Brazil;
Sandra Dur~aes, MD, Hospital Universit
ario Antonio Pedro, Niteroi, Brazil

Tattoo inoculation leprosy in a patient treated for pulmonary tuberculosis

Catherine Foley, MBBCh, St. Jamess Hospital, Dublin, Ireland; Benvon Moran,
MBBCh, St. Jamess Hospital, Dublin, Ireland; Joseph Keane, MD, St. Jamess
Hospital, Dublin, Ireland; Louise Barnes, MBBCh, St. Jamess Hospital, Dublin,
Ireland; Peter Branagan, MD, St. Jamess Hospital, Dublin, Ireland

Background: Syphilis is a communicable disease, sexually transmitted, caused by

Treponema pallidum. Syphiliss natural course goes on through symptomatic and
asymptomatic stages. Secondary syphilis starts among 6 to 8 weeks after chancres
(primary lesion) appearance and affects skin and internal organs. It is characterized
by a polymorphism of symmetrical, asymptomatic, treponema rich and highly
infective skin lesions.
Case report: A 22-year-old male natural from Rio de Janeiro, presented 2 months
before, a lonely sore in the penis, which had spontaneous regression. After 1 month
nonpruritic lesions appeared all over the body. He denied systemic symptoms. Has
sexual intercourse without condoms. Exam: erythematous papular lesions, some
with crust and others with peripheral flaking spread through chest and limbs,
erythematous papular lesions in the face, some infiltrative and coalescent; retroauricular, cervical and bilateral inguinal lymphadenomegaly. Histopathologic examination was compatible with secondary syphilis. VDRL was positive (1/64), FTA-abs
reactive and anti-HIV negative. The patient was treated with benzathine penicillin
2,400,000 IU in 2 doses, one per week. After first dose the lesions presented
important improvement.
Discussion: Initially, secondary lesions occur in outbreaks and can present with
erythematous macula (syphilitic roseola) of short duration. New breakouts occur
with erythematous papular, rounded, covered by thin scales mainly on the
periphery (Biett collarette) of the lesions. Macules, papulae and even pustules can
occur concomitantly, accompanied by generalized polyadenomegaly and nonspecific general symptoms. This polymorphism of lesions makes secondary syphilis acts
like a simulator, which can be confused with many diseases, like leprosy, drug
eruption and pityriasis rosea. Sometimes, as in this case, the history of the primary
lesion was important for the clinical reasoning. A lumbar puncture should be
performed in any HIV positive patient, however, in nonecoinfected ones, it should
be performed only in case of neurologic symptoms, latent syphilis and in therapeutic
failures. Syphiliss treatment is still based on benzathine penicillin efficacy. Avoiding
the spread of the disease consists on the detection and on the early and adequate
treatment of the patient and its partner. It is important to stimulate the use of
condoms once syphilis does not confer immunity, and in this way reinfection is
possible.

A 17-year-old boy from Congo presented with a 3-week history of an asymptomatic

rash on the right upper limb. He had a background of recently diagnosed pulmonary
tuberculosis, and had started rifampicin, isoniazid, pyrazinamide, ethambutol and
pyridoxine 7 weeks before the onset of the rash. He had erythematous papules and
nodules within a preexisting tattoo on the right arm. One week later he developed
an erythematous papulosquamous eruption on the right distal forearm and wrist,
with associated weakness of the fourth and fifth digits and a fixed flexion deformity
of the little finger with extension at metacarpal phalangeal joint and flexion at the
distal interphalangeal joint. Nerve conduction studies showed an absent digit five
sensory response and dorsal ulnar cutaneous sensory response. Ulnar motor
response showed low amplitude distally at abductor digiti minimi, consistent with
a focal right ulnar neuropathy. Radial and medial nerve function was intact. Biopsies
from the right arm and distal forearm revealed florid non-necrotizing granulomatous
inflammation and scanty acid-fast bacilli, with tattoo pigment admixed within the
infiltrate from the former. PCR was negative for tuberculous and common nontuberculous mycobacteria. The specimens were culture-negative after seven weeks
inoculation at 308C and 378C. DNA was extracted from the skin biopsy and
molecular assay isolated Mycobacterium leprae. HIV testing was negative. The
combination of skin, neurologic and laboratory findings was consistent with a
diagnosis of leprosy, clinically manifesting two weeks after the introduction of
antituberculous treatment. Immune reconstitution inflammatory syndrome in HIVnegative patients with tuberculosis has been reported, and may be the cause of the
occurrence or unmasking of the leprosy-associated rash and neuropathy after
starting anti-tuberculous therapy. This patient developed the lepromatous rash
within a tattoo, which he had got in Congo 2 years before presentation. In our
opinion this is likely a case of tattoo-inoculation leprosy. Inoculation leprosy has
been reported from armadillo bites, trauma, contaminated vaccination needles, as
well as tattoos. Our patient continued antituberculous treatment, and clofazamine,
minocycline and ofloxacin were added to treat the leprosy infection. Dapsone was
not given because of G6PD deficiency. Prednisolone was given to treat the ulnar
neuropathy, with good effect.
Commercial support: None identified.

Commercial support: None identified.

P6684

P6472
Simultaneous primary and secondary syphilis in an HIV-positive patient
Isabel Cristina Valente Duarte de Sousa, MD, Centro Dermatol

ogico del Valle,
Delegaci

on Benito Juarez, Mexico

The Edinburgh experience of cutaneous Mycobacterium chelonae

infection
Victoria Scott-Lang, MBChB, Royal Infirmary of Edinburgh, Edinburgh, United
Kingdom; Alex Holme, MBChB, MD, Royal Infirmary of Edinburgh, Edinburgh,
United Kingdom; Gina Kavanagh, MBChB, Royal Infirmary of Edinburgh,
Edinburgh, United Kingdom; Ian Laurenson, MBChB, Royal Infirmary of
Edinburgh, Edinburgh, United Kingdom

Syphilis is a systemic disease caused by Treponema pallidum. The disease has been
divided into a series of stages based on clinical findings. The first stage of syphilis,
known as primary syphilis, is marked by the presence of a chancre (a painless ulcer
with sharp borders that resolves within 3 to 6 weeks). Secondary syphilis is
characterized by systemic symptoms (fever, headache, myalgias, lymphadenopathy)
and the presence of a generalized maculopapular scaly eruption on the torso and
extremities. The palms and soles are affected in 60% of cases. Tertiary syphilis is
characterized by cardiovascular, neurologic and gummatous lesions. In HIV positive
patients the simultaneous manifestations of primary and secondary syphilis is not
uncommon because the chancre is likely to persist into the secondary stage.
Diagnosis is definitive with dark field microscopy during the chancre phase. For
secondary or tertiary syphilis serologic test such as Venereal Disease Research
Laboratory (VDRL) are useful, but are mainly used to monitor response to treatment.
Treatment of primary and secondary syphilis among HIV-infected adults is with
penicillin G benzathine, 2.4 million units in a single dose intramuscular injection. In
case of penicillin allergy, ceftriaxone might be a proper alternative5. HIV-infected
patients should be evaluated clinically and serologically at 3, 6, 9, 12, and 24 months
after therapy. A 30-year-old man presented with a 5-week history of a painless, welldemarcated penile ulcer. One week before the consultation, he had also noted the
appearance of non-pruritic scaly macules and papules on arms, palms and soles. His
medical history included HIV diagnosed 5 years earlier. Simultaneous primary and
secondary syphilis was immediately suspected. Darkfield microscopy revealed
treponema, while the VDRL count was positive at a titre of 1:128. Treatment was
initiated with a single dose of penicillin G benzathine 2.4 million units administered
intramuscularly. Six months later, the patient was free of cutaneous lesions, and the
VDRL had dropped to a 1:4 titre, indicating a remarkable response to treatment. In
HIV-positive patients, it is important to remember that the described clinical stages
of syphilis may overlap, and that simultaneous primary and secondary syphilis is
common, even though systemic symptoms of the latter may be absent.

We present 3 patients with cutaneous Mycobacterium chelonae infection. All 3

patients were immunosuppressed on long-term prednisolone. A 58-year-old woman
presented in 1988 with tender nodules on her limbs. Her skin biopsy showed
features of nodular vasculitis. She was started on prednisolone 10 mg in 1993 for
vasculitis and was lost to follow-up. She continued on prednisolone until she
presented aged 81 with an osteoporotic wedge fracture. Shortly after reducing
prednisolone she developed a new suppurative nodules on her left wrist. A skin
biopsy was taken for histology and culture. The biopsy showed many acid fast
bacilli, and culture subsequently identified M chelonae. A 3-month course of oral
clarithromycin resulted in complete resolution. An 85-year-old woman on prednisolone for giant cell arteritis was referred to dermatology by rheumatology colleagues
with suppurative nodules on her right forearm and hand. A skin biopsy again
showed acid fast bacilli, and M chelonae was cultured. A 3-month course of
clarithromycin resulted in complete clearance. The third patient, an 85-year-old
woman, on long-term prednisolone for polymyalgia rheumatica, was referred with
pustules and nodules on her left leg. Atypical mycobacterial infection was
suspected, and a skin biopsy subsequently cultured M chelonae. She was treated
with a 6-month course of clarithromycin and rifampicin, and had a complete
response. We performed a database search for all cases of cutaneous mycobacterial
infection in Scotland over 10 years from January 2002 to December 2011, using the
Scottish Mycobacteria Reference Laboratory. There were 123 cases in total and the
frequency of organism was as follows: M tuberculosis (63); M chelonae (16); M
marinum (15); BCG (9); M avium (6); M fortuitum (3); M malmoense (3); M
gordonae (2); M intracellulare (2); M kansasii (1); M scofulaceum (1); M palustre
(1); and M simiae (1). There were 7 patients with M chelonae within our Health
Board. Five of these patients were on immunosuppressive therapy (71%).
Immunosuppression is a risk factor for contracting atypical mycobacterial infection.
The most common atypical mycobacterium identified in our study was M chelonae.
This diagnosis should be considered particularly in immunosuppressed patients
who present with suppurative nodules and plaques.

Commercial support: None identified.

Commercial support: None identified.

AB124

J AM ACAD DERMATOL

APRIL 2013