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Tertiary syphilis: tubero-serpiginous and tubero-ulcerous syphilids.

A 50-year-old heterosexual, HIV seronegative, male patient presented at the Dermatology Service with asymptomatic erythematous lesions on his left elbow and forehead for four months. He denied previous treatment, comorbidities and had no systemic symptoms. The dermatological examination showed erythematous purplish tuberous circinate plaque on his forehead (Fig. 1A), reddish purplish tubers, some ulcerated on the left elbow (Fig. 1B), and bulky lymphadenopathy in the neck (Fig. 1C); absence of mucosal lesions; preserved skin sensitivity and peripheral nerves without changes. Test results: VDRL1/64, TPHA reagent, and anti-HIV nonreactive. The diagnosis of tertiary syphilis was established and treatment with penicillin benzathine 7,200,000 IU in three weekly intramuscular doses of 2,400,000 IU was administered. Reduction of the lesion was observed one week thereafter and clinical cure was achieved after the end of treatment (Fig. 2).

Syphilis is a millenarian disease but still remains rather prevalent, especially in some high-risk behavior individuals. (1,2) In contrast to the increasing incidence of early syphilis (primary and secondary), cases of classic late syphilis (tertiary) as a result of untreated syphilis are rarely seen. (3,4) Approximately half of patients with tertiary syphilis presents "benign" late syphilis with gums emergence. (4,5) Around a quarter develop cardiovascular manifestations and another quarter develop neurological symptoms. (4,6) Gums are locally destructive lesions in the skin, liver, bones, and other organs. (4,7) Skin gums are nodular or nodular ulcerative lesions, with an arciform pattern. (3,4)



Article history:

Received 16 January 2016

Accepted 19 January 2016

Available online 26 March 2016

Conflicts of interest

The authors declare no conflicts of interest.


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(3.) Avelleira JCR, Bottino G. Syphilis: diagnosis, treatment and control. An Bras Dermatol. 2006; 81:111-26.

(4.) Stary A, Stary G. Infeccoes Sexualmente Transmissiveis (Sifilis). In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. 3rd ed. New York: Mosby Elsevier; 2015. p. 1367-79.

(5.) Wu SJ, Nguyen EQ, Nielsen TA, Pellegrini AE. Nodular tertiary syphilis mimicking granuloma annulare. J Am Acad Dermatol. 2000; 42:378-80.

(6.) Revathi TN, Bhat S, Asha GS. Benign nodular tertiary syphilis: a rare presenting manifestation of HIV infection. Dermatol Online J. 2011; 17:5.

(7.) Rocha N, Horta M, Sanches M, Lima O, Massa A. Syphilitic gumma--cutaneous tertiary syphilis. J Eur Acad Dermatol Venereol. 2004; 18:517-8.

Livia Montelo Araujo Jorge (a),*, Jose Augusto da Costa Nery (b), Fred Bernardes Filho (c)

(a) Dermatology Service, Policlinica Geral do Rio de Janeiro, Rio de Janeiro, RJ, Brazil

(b) Laboratorio de Hanseniase--Fundacao Oswaldo Cruz (LaHan-Fiocruz), Rio de Janeiro, RJ, Brazil

(c) Dermatology Division, Department of Medical Clinics, Faculdade de Medicina de Ribeirao Preto, Universidade de Sao Paulo (USP), Ribeirao Preto, SP, Brazil

* Corresponding author.

E-mail address: (L.M.A. Jorge).
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Title Annotation:Clinical image
Author:Jorge, Livia Montelo Araujo; Nery, Jose Augusto da Costa; Filho, Fred Bernardes
Publication:The Brazilian Journal of Infectious Diseases
Article Type:Clinical report
Date:May 1, 2016
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