Canadian Journal of General Internal Medicine
32 Volume 14, Issue 4, 2019
Lymphomatoid Papulosis in a Case
ofAtypicalSecondary Syphilis
Xin Mu, BSc, Ian Mazzetti, MD FRCPC
About the Authors
Xin (Peter) Mu is a 1st-year IM resident at Memorial University, Newfoundland.
Dr. Ian Mazzetti is an intensivist and a member of the critical care team at the Windsor Regional Hospital.
Corresponding Author: ian.mazzetti@medportal.ca
Submitted: December 10, 2018. Accepted: January 18, 2019. Published: November 19, 2019. DOI: 10.22374/cjgim.v14i4.335
Clinical Images
Abstract
Lymphomatoid papulosis is an indolent cutaneous lymphoproliferative disorder that presents
as recurrent self-resolving papulonodular skin lesions. Currently, there are no known causes for
lymphomatoid papulosis and definitive diagnosis is only made histologically. A 64-year-old man
presented with a 6-week history of bilateral leg pains, low-grade fevers, and a widespread eruption
of painless erythematic papules. Despite testing positive for syphilis serology, he lacked the typical
clinical history for classic syphilis and therefore, skin biopsies were performed to confirm the
diagnosis. Unexpectedly, the skin biopsies revealed lymphomatoid papulosis which resolved
with antibiotic treatments for syphilis. Considering the synchronous resolution of the patients
syphilis infection and his cutaneous lesions, this is the first report of findings to suggest syphilis
as a possible cause for lymphomatoid papulosis. Clinicians should appreciate the possibility of
alternative diagnosis for cutaneous presentations in settings of confirmed syphilis infections.
RESUME
La papulose lympho-matoïde est un trouble lymphoprolifératif cutané indolent qui se présente
sous la forme de lésions cutanées papulonodulaires auto-résolutives récurrentes. Actuellement,
il ny a pas de causes connues de la papulose lymphomatoïde et le diagnostic définitif nest posé
que sur le plan histologique. Un homme de 64 ans a présenune histoire de 6 semaines de
douleurs bilatérales aux jambes, de fièvres de bas grade et déruptions généralisées de papules
érythémateuses indolores. Malgré un test sérologique positif pour la syphilis, il navait pas les
antécédents cliniques typiques de la syphilis classique et des biopsies cutanées ont donc été
effectuées pour confirmer le diagnostic. De façon inattendue, les biopsies cutanées ont révélé
une papulose lymphomatoïde qui sest résorbée grâce à des traitements antibiotiques contre la
syphilis. Compte tenu de la résolution synchrone de l’infection syphilitique du patient et de
ses lésions cutanées, il sagit du premier rapport de résultats suggérant que la syphilis est une
cause possible de papulose lymphomatoïde. Les cliniciens devraient apprécier la possibilité d’un
diagnostic alternatif pour les présentations cutanées dans les contextes d’infections syphilitiques
confirmées.
CJGIM_4_2019_172948.indd 32 11/8/19 12:18 PM
Canadian Journal of General Internal Medicine
Volume 14, Issue 4, 2019 33
Clinical Image
A 64-year-old man was admitted to our institution with the
progressive eruption of widespread rashes in the context of
lancinating leg pains, recurrent fevers, and subacute development
of asymptomatic lung opacities noted on recent CT chest.
Examination revealed the presence of diffuse, non-pruritic,
painless erythematic papules most predominantly concentrated
in the chest, trunk, and lower limbs with no mucosal involvement
(Figur 1). Following an initial infectious workup, the patient
was found with positive Treponema pallidum serology and was
started on penicillin G treatment. Due to inconsistencies in the
patients reported history, skin biopsies were obtained to confirm
a diagnosis of secondary syphilis. Surprisingly, the biopsy results
showed lymphomatoid papulosis (LyP); a rare form of primary
cutaneous lymphoproliferative disorder. In consideration of
recent pulmonary infiltrates and the absence of neurosyphilis,
this is most likely an atypical presentation of secondary syphilis
given the alternative cutaneous findings.
1
Nevertheless, the
patient saw a regression of his syphilis infection as well as LyP
lesions with antibiotic treatment.
LyP is a chronic benign lymphoproliferative disorder that is
characterized by recurrent eruptions of erythematic papulonodular
lesions.
2
The etiology of LyP is currently unknown and the genetic
abnormalities behind LyP’s immunophenotypic features appear
to be complex with a high degree of variation among individual
cases
2
. Despite being long hailed as the “great imitator” due
to its lengthened clinical course and variable presentations,
Mu et al.
syphilis is rarely considered as an etiology for the development
of lymphoproliferative disorders. Connections between syphilis
and lymphoproliferative disorders may have been overlooked by
the urge to attribute abnormalities—clinically or histologically—
as manifestations of syphilis given its protean nature. Given
the regression of LyP with syphilis treatment, syphilis should
be considered as a risk factor for the development of chronic
cutaneous lymphoproliferative disorders.
Consent
The patient provided informed consent for the use of photographs
and other health information contained in this publication and
is aware of the context of such use.
Conflicts of Interests
The authors have no actual or potential conflicts of interest to
declare.
Sources of Funding
No funding was obtained for the publication of this article.
References
1. David G, Perpoint T, Boibieux A, et al. Secondary pulmonary syphilis: report
of a likely case and literature review. Clin Infect Dis 2006;42:1–5.
2. De Souza A, El-Azhary RA, Camilleri MJ, et al. In search of prognostic
indicators for lymphomatoid papulosis: A retrospective study of 123 patients.
J Am Acad Dermatol 2012;66:928–37.
Figure 1. Clinical photographs of the patient’s initial presentation: A. Diffuse erythematic
papular lesions are most notably seen over the patient’s chest. B. Lesions were also
identified to a lesser extent on the patient’s extremities.
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