Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.
- Presentation
Nodular Secondary Syphilis Mimicking PTLD in an Immunosuppressed Transplant Patient
Description
A chronically immunosuppressed man in his 50s with a renal transplant developed a persistent, spreading polymorphic rash with fever and malaise. The biopsy showed a dense nodular lymphohistiocytic infiltrate that initially raised concern for post-transplant lymphoproliferative disorder, infection, drug eruption, or other inflammatory mimics. Extensive immunostains and clonality studies did not support lymphoma or PTLD, and chart review revealed prior dizziness and ocular inflammation, prompting reconsideration of the lesion. Closer histologic review showed more plasma cells than first appreciated, and a treponema stain revealed numerous spirochetes, leading to the diagnosis of nodular secondary syphilis with associated neurosyphilis. The patient improved after IV penicillin G, and the earlier biopsy was reinterpreted as an early manifestation of secondary syphilis. The talk emphasized how syphilis can mimic many conditions and highlighted diagnostic pitfalls such as premature closure, anchoring bias, prestige bias, and diagnosis momentum.
View moreConclusions
- The case shows that nodular secondary syphilis can closely mimic post-transplant lymphoproliferative disorder, drug eruption, and other inflammatory or infectious dermatoses in immunosuppressed patients.
- A dense nodular lymphoplasmacytic infiltrate with relatively little epidermal change should prompt consideration of syphilis even when the initial differential suggests lymphoma or dermatitis.
- Careful clinicopathologic correlation and willingness to revisit the biopsy can uncover an early syphilitic process that was initially interpreted as subtle interface dermatitis.
- Special stains and additional workup, including Treponema staining, may be decisive when routine histology and initial immunostains are nondiagnostic.
- The patient improved with IV penicillin, supporting the diagnosis of secondary syphilis with associated neurosyphilis.
- This case illustrates that syphilis remains a major masquerader and should stay on the differential in immunocompromised patients with atypical rashes.
- Premature closure, anchoring bias, prestige bias, and diagnosis momentum can all contribute to missed or delayed recognition of syphilis and other mimics.
- BMJ Case Reports, “The pitfalls of premature closure: clinical decision-making in a case of aortic dissection.”#10.1136/bcr.08.2011.4594