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Year : 2019  |  Volume : 62  |  Issue : 2  |  Page : 339-340
Cervical syphilitic lymphadenitis causing fever of unknown origin followed by rash of secondary syphilis


1 Department of Infectious Diseases, Stony Brook University Hospital, Stony Brook, NY 11794, USA
2 Department of Pathology, Northport Veterans Affairs Medical Center, Northport, NY 11768, USA
3 Division of Infectious Diseases, Northport Veterans Affairs Medical Center, Northport, NY 11768, USA

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Date of Web Publication10-Apr-2019
 

How to cite this article:
Mahapatra R, Clarke G, Lobo Z, Psevdos G. Cervical syphilitic lymphadenitis causing fever of unknown origin followed by rash of secondary syphilis. Indian J Pathol Microbiol 2019;62:339-40

How to cite this URL:
Mahapatra R, Clarke G, Lobo Z, Psevdos G. Cervical syphilitic lymphadenitis causing fever of unknown origin followed by rash of secondary syphilis. Indian J Pathol Microbiol [serial online] 2019 [cited 2019 May 23];62:339-40. Available from: http://www.ijpmonline.org/text.asp?2019/62/2/339/255805




Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. The organism can be transmitted through oral sexual contact causing a mucosal surface chancre. The chancre is usually painless and it can go unnoticed as it resolves spontaneously without treatment. Cervical lymphadenitis can be a localized reaction to this primary syphilitic lesion. In general, syphilitic lymphadenopathy can be detected during any of the three stages of disease, or during intervals between stages.[1] Syphilis is known to play strange tricks on clinicians, as the great mimicker, making clinical diagnosis anything but easy. Herein, we described a case of cervical syphilitic lymphadenitis initially masquerading as lymphoma causing a febrile illness, but later “revealing” itself in a rash with serological confirmation and dermatopathological evaluation showing the spirochetes in the epidermis.

A 66 year-old gentleman presented to our practice with intermittent febrile illness of a month's duration with nocturnal diaphoresis, chills, and a 10 pound unintentional weight loss. A physical examination revealed enlarged, fixed, cervical lymph nodes, mild pharyngeal erythema but without any ulcers. A soft systolic heart murmur was audible. A computed tomography imaging showed multiple enlarged bilateral cervical lymph nodes, largest measuring 1.9 × 1.3 cm on the right and 2.0 × 1.8 cm on the left, and an enlarged supraclavicular lymph node, measuring 1.5 × 2.1 cm [Figure 1]. An excisional lymph node biopsy was performed to rule out a lymphoproliferative disorder. Histologic analysis showed a non-necrotizing granulomatous reaction with giant cell formation [Figure 2]a. Acid fast, Gomori methenamine- silver nitrate, and periodic acid-Schiff stains were negative for organisms. A flow cytometry confirmed absence of immunophenotypic evidence for clonal B-cell or abnormal T-cell population. The patient did not have bacteremia, Bartonella titers were negative, and the fever resolved spontaneously. Three weeks later the patient presented with a papulonodular erythematous rash on the trunk and buttocks, sparing the palms and soles. At that time the lymphadenopathy had resolved. The patient admitted to having unprotected oral sex. A skin punch biopsy revealed an acanthotic skin with focal inflamed ulcer with epidermal spongiosis and plasma cell predominant inflammation [Figure 2]b. An immunoperoxidase stain for Treponema pallidum showed numerous intraepidermal spirochetes [Figure 3]a and [Figure 3]b. Rapid plasma reagin titer was 1:128 and the patient was treated with a single intramuscular dose of benzathine penicillin G.
Figure 1: CT imaging of neck: (A) Cervical lymph nodes. (B) Supraclavicular lymph node

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Figure 2: (a) H and E stain, lymph node, showing non-necrotizing granulomatous reaction (b) H and E stain, epidermal spongiosis and plasma cell predominant inflammation

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Figure 3: (a) Immunoperoxidase stain showing numerous intra-epidermal spirochetes (b) immumoperoxidase stain at higher magnification

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Syphilitic or luetic lymphadenopathy usually has features of follicular hyperplasia and often marked by medullary and interfollicular plasmacytosis.[2] Previous reports have described syphilitic lymphadenitis as isolated enlarging neck masses.[3] Nonnecrotizing granulomas with epithelioid histiocytes and giant cells are common. Diagnosis can be confirmed by the detection of the spirochete via silver staining, immunohistochemistry, and PCR testing.[4]

Immunohistochemical staining of the cervical node in our case did not show evidence of spirochetes. In a retrospective study to elucidate the pathologic features of syphilitic lymphadenitis, Liu et al. reported that 15 of 16 cases identified Treponema pallidum by immunohistochemical staining of pathology specimens.[5] However, others have reported that Silver impregnation stains are relatively insensitive for the detection of treponemal organisms and that syphilitic lymphadenopathy can present with a constellation of histologic findings that may mimic other infectious or neoplastic processes. These findings include capsular fibrosis, chronic inflammation, follicular and interfollicular hyperplasia, and perivascular cuffing of plasma cells, among other findings.[6] Therefore, the importance of obtaining clinical history and elucidating possible epidemiologic exposures is crucial in the timely diagnosis of syphilitic lymphadenitis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Miranda RN, Khoury JD, Medeiros LJ. Syphilitic lymphadenitis. In: Atlas of Lymph Node Pathology. Atlas of Anatomic Pathology. New York: Springer; 2013.  Back to cited text no. 1
    
2.
Xie Y, Vallangeon B, Liu X, Lagoo AS. Plasmacytic or lymphoplasmacytic infiltrate in lymph nodes: Diagnostic approach and differential considerations. Indian J Pathol Microbiol 2016;59:446-56.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Jang DW, Khan A, Genden EM, Wu M. Syphilitic lymphadenitis diagnosed via fine needle aspiration biopsy. Diagn Cytopathol 2011;39:603-5.  Back to cited text no. 3
    
4.
Behrhof W, Springer E, Bräuninger W, Kirkpatrick CJ, Weber A. PCR testing for Treponema pallidum in paraffin-embedded skin biopsy specimens: Test design and impact on the diagnosis of syphilis. J Clin Pathol 2008;61:390-5.  Back to cited text no. 4
    
5.
Liu Z, Zhang C, Kakudo K, Cui X, Mu K, Zhou C, et al. Diagnostic pitfalls in pathological diagnosis of infectious disease: Patients with syphilitic lymphadenitis often present with inconspicuous history of infection. Pathol Int 2016;66:142-7.  Back to cited text no. 5
    
6.
Farhi DC, Wells SJ, Siegel RJ. Syphilitic lymphadenopathy. Histology and human immunodeficiency virus status. Am J Clin Pathol 1999;112:330-4.  Back to cited text no. 6
    

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Correspondence Address:
George Psevdos
Northport Veterans Affairs Medical Center, 79 Middleville Rd, Northport, NY 11768
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_188_18

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