The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Lindsey R. Baden, M.D., Editor

Primary and Secondary Syphilis

A B

C D

Michael P. Schön, M.D.

Hans P. Bertsch, M.D.
University Medical Center Göttingen
Göttingen, Germany
michael.schoen@med.uni-goettingen.de

A
previously healthy 68-year-old man presented with a solid erosive sore on the inner aspect
of his upper lip (Panel A). The painless lesion had been present for approximately 6 weeks. On examination,
the patient had sharply demarcated erythematous, scaly plaques on his hands and feet, including the palms
and soles (Panels B, C, and D). The patient reported that the lesions were waxing and waning and had been present
for more than 1 year. There were no other symptoms. Laboratory investigations revealed a positive Treponema pallidum
particle agglutination assay (titer, 1:2560; normal value, <1:80) and a positive Venereal Disease Research Laboratory
test (titer, 1:8; normal value, <1:2). Serologic tests for human immunodeficiency virus and hepatitis were negative.
Immunoblot analyses were positive for syphilis-specific IgM and IgG. Histopathological analyses of biopsy speci-
mens obtained from the lip lesion and a representative lesion from the foot showed ulceration of the lip lesion and
psoriasiform hyperplasia of the foot lesion; both specimens were associated with abundant CD79a-positive plasma
cells and masses of T. pallidum bacteria (Fig. S1 in the Supplementary Appendix, available with the full text of
this article at NEJM.org). Concomitant primary and secondary syphilis was diagnosed. Intramuscular injections
of penicillin G benzathine (three injections in 4-week intervals at a dose of 2.4×106 IU) led to complete resolution of
the lesions within 2 months and to substantially decreased titers on laboratory tests. The concomitant presence
of primary and secondary syphilis in the same patient is unusual; however, it is possible to acquire a superimposed
second infection.
DOI: 10.1056/NEJMicm1502476
Copyright © 2016 Massachusetts Medical Society.

372 n engl j med 374;4 nejm.org January 28, 2016

The New England Journal of Medicine

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