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JAMA Dermatology Clinicopathological Challenge |

Abrupt Onset of Ulcerative Papules and Nodules on the Face and Genitals QUIZ

Lauren Chantel Payne, MD, MS, BS1; Keith Michael Egan, DO, BS2; Nasir Aziz, MD, MA, BA3
[+] Author Affiliations
1Department of Dermatology, Howard University Hospital, Washington, DC
2The Wright Center for Graduate Medical Education, Washington, DC
3Veterans Affairs Medical Center, Washington, DC
JAMA Dermatol. 2016;152(7):829-830. doi:10.1001/jamadermatol.2016.0017.
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A man in his 60s with a medical history of hypertension, cerebrovascular accident, colon cancer, and remote cocaine use presented with numerous pruritic crusted papules and nodules on the face and genitals. The eruption presented abruptly over a 2-week course and the patient denied recent sexual intercourse, penile discharge, fevers, chills, nausea, or vomiting. What is your diagnosis?

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Figure.

A, Multiple crusted and ulcerative papules and nodules on the face. B, Multiple ulcerated healing papules on the scrotum and umbilicated papules on the left inner thigh. C, Low-power image (hematoxylin-eosin, original magnification ×40). D, A Warthin-Starry silver impregnation stain (original magnification ×40).

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Neurosyphilis Evaluation in Persons with Syphilis
Posted on March 22, 2016
Kenneth A. Katz MD MSc MSCE, Ata S. Moshiri MD MPH, Stephanie E. Cohen MD MPH
Katz: Department of Dermatology, Kaiser Permanente, Pleasanton, CA; Moshiri: Department of Dermatology, University of Pennsylvania, Philadelphia, PA; Cohen: San Francisco Department of Public Health,
Conflict of Interest: None Declared
As the incidence of syphilis rises in the United States, dermatologists’ competence in diagnosing and managing syphilis is increasingly important. A recent article1 described a case of lues maligna, a manifestation of secondary syphilis, in a man without neurologic or ophthalmic abnormalities. A lumbar puncture showed cerebrospinal fluid (CSF) pleocytosis, leading to intravenous penicillin treatment, “out of concern for tertiary syphilis.”1 The case raises important issues related to neurosyphilis in persons with syphilis.

First, neurosyphilis can occur during any stage of syphilis, not just during tertiary syphilis.2 Neurosyphilis is classified as early or late. Late neurosyphilis includes tabes dorsalis and general paresis.2 Early neurosyphilis includes neurologic and ophthalmologic manifestations occurring before or during primary, secondary, or early latent syphilis.2 In one study, early neurosyphilis (manifesting as cranial nerve abnormalities, meningitis, stroke, headache, and/or altered mental status ) affected 1.7 percent of persons, of whom 30 percent experienced persistent symptoms six months after treatment.3 More recently, clusters of ocular syphilis cases, including uveitis and vision loss, have occurred in several U.S. cities.4 For those reasons, CDC recommends assessing every person with syphilis for neurologic and ophthalmic disease.5

Second, cerebrospinal fluid (CSF) examination should be limited to specific scenarios. CSF abnormalities, including pleocytosis, are common but not necessarily clinically significant in adults with primary or secondary syphilis.5 Therefore, CDC limits indications for CSF examination to the following: neurologic or ophthalmic symptoms or signs suggestive of neurosyphilis; treatment failure; or tertiary syphilis.5 Neither high-titer disease nor lues maligna is, in and of itself, an indication for CSF examination, according to current CDC guidelines.5

Evaluation for neurosyphilis is a critical part of managing syphilis5, including for dermatologists. Effective neurosyphilis evaluation can lead to prompt diagnosis and care, forestalling potentially permanent sequelae. Equally importantly, guideline-based evaluation for neurosyphilis can avert unnecessary procedures and treatment when not required.

REFERENCES
1. Payne LC, Egan KM, Aziz N. Abrupt Onset of Ulcerative Papules and Nodules on the Face and Genitals. JAMA Dermatology. Published online March 2, 2016.
2. Marra CM. Update on neurosyphilis. Curr Infect Dis Rep. 2009;11:127-34.
3. CDC. Symptomatic early neurosyphilis among HIV-positive men who have sex with men – four cities, United States, January 2002-June 2004. MMWR 2007;56:625-8. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a1.htm.
4. Woolston S, Cohen SE, Fanfair RN, et al. A Cluster of Ocular Syphilis Cases – Seattle, Washington, and San Francisco, California, 2014-2015. MMWR. 2015;64:1150-1. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6440a6.htm.
5. Workowski KA, Bolan GA. STD Treatment Guidelines 2015. MMWR Recomm Rep 2015;64(RR-03):1-137.
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