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Syphilis presenting as erosive papules on the palate

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Syphilis presenting as erosive papules on the palate
Rym Benmously Mlika1, Samy Fenniche1, Elhem Khelifa1, Hayet Marrak1, Achraf Debbiche2, Olfa Khayat2, Mohamed Ben Ayed2, Inçaf Mokhtar1
Dermatology Online Journal 11 (1): 23

From the Departments of Dermatology1 and Anatomo-pathology2, Habib Thameur Hospital, Tunis-Tunisia.

Clinical synopsis

A 43-year-old healthy woman is referred to our dermatology department for evaluation of asymptomatic erosions involving the palate and the abdomino-pelvic fold; these lesions began 15 days prior. No history of family disease is noted. Physical examination reveals gray erosive papules with red areolae located on the palate (Fig. 1). A similar 2-cm lesion is found on the abdominal fold (Fig. 2). Diffuse alopecia of eyelashes, eyebrows, and the scalp is also noted. Palms and soles are not affected.

A biopsy specimen from the erosive lesion of the abdominal fold shows hyperplasia of the epidermis with a pleomorphic mononuclear perivascular infiltrate of the dermis (Figs. 3, 4).

Laboratory studies reveals slight eosinophilia. Screening for hepatitis viruses and HIV are negative.

Figure 1 Figure 2
Circular gray erosions with a red areola involving the palate (Fig. 1).
Erythematous erosion of the abdomino-pelvic fold (Fig. 2)

Figure 3 Figure 4
Hyperplasia of the epidermis with a pleomorphic mononuclear perivascular infiltrate of the dermis (Fig. 3).
Many mature plasma cells associated with marked endothelial swelling within the dermis (Fig. 4).

Examination of the biopsy specimen shows a psoriasiform hyperplasia of the epidermis. A dense inflammatory-cell infiltrate is present in both papillary and reticular dermis (Fig. 3). Higher magnification reveals a pleomorphic perivascular infiltrate with many mature plasma cells in association with marked endothelial swelling (Fig. 4). These histological features are suggestive of secondary syphilis. Nontreponemal serology screening using venereal disease research laboratory (VDRL) shows a titer of 1:64, and Treponema pallidum hemagglutination assay (TPHA) is positive at the high titer of 1:20,480.


Despite the progress in syphilis control in our country, an increase in the incidence of this disease has been recently noted. In our dermatology department, the latest case of syphilis occurred in 1990. Since that date, four new patients have been diagnosed between June 2002 and April 2004 (Table I). As seen in the present case, all patients had secondary syphilis and were immunocompetent [1].

This alarming resurgence of the disease is not a specific phenomenon to Tunisia. In fact, similar data are reported in Europe and in the United States. In the United Kingdom, syphilis epidemics are observed in Manchester among homosexual population (41 cases from January 1993 to March 2001) and also in Brighton (31 cases from July 1999 to July 2001). The highest incident rate of syphilis is registered in Dublin with more than 121 cases of early syphilis over an 18-month period [2].

In the United States, syphilis incidence rates among heterosexuals are highest in the South (53 % of all United States cases in 2001). Syphilis affected 42 times more black women than white women [3, 4]. In Washington, the rate of early syphilis in homosexuals is estimated at about 141 per 100,000 [4].

This resurgence of syphilis is attributed to a decrease in prevention activities. A greater vigilance by doctors here appears to be necessary because our patients are already presenting with secondary syphilis. Improvement in medical education is therefore urgently needed to enable effective control of syphilis and other sexually transmitted infections especially in young people and high-risk groups.


1. Fenniche S, Ben Ammar F, Marrak H, Benmously R, Mokhtar I. Syphilis chez l'immunocompétent : 3 cas. Ann Dermatol Venereol 2003;130:4S265-4S72.

2. Fenton KA, Nicoll A, Kinghorn G. resurgence of syphilis in England: time for more radical and nationally coordinated approaches. Sex Transm Inf 2001;77:309-10. PubMed

3. CDC. Primary and secondary syphilis- United states 1999. Morb Mortal Wkly Rep 2001 23;50:113-7. PubMed

4. Golden MR, Marra CM, Holmes KK. Update on syphilis. Resurgence of an old problem. JAMA 2003;290:1510-1514. PubMed

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