Dermatologica Sinica

: 2019  |  Volume : 37  |  Issue : 3  |  Page : 172--173

A case of secondary syphilis manifesting erythema multiforme-like skin lesions

Andrew Y Wirya1, Hiraku Suga2, Ivan Kurniadi2, Tomomitsu Miyagaki2, Miki Miyazaki2, Shinichi Sato2,  
1 Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan; Faculty of Medicine, Airlangga University, Surabaya, Indonesia
2 Department of Dermatology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan

Correspondence Address:
Dr. Hiraku Suga
Department of Dermatology, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655

How to cite this article:
Wirya AY, Suga H, Kurniadi I, Miyagaki T, Miyazaki M, Sato S. A case of secondary syphilis manifesting erythema multiforme-like skin lesions.Dermatol Sin 2019;37:172-173

How to cite this URL:
Wirya AY, Suga H, Kurniadi I, Miyagaki T, Miyazaki M, Sato S. A case of secondary syphilis manifesting erythema multiforme-like skin lesions. Dermatol Sin [serial online] 2019 [cited 2022 Aug 18 ];37:172-173
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Full Text

Dear Editor,

Secondary syphilis typically manifests up to 10 weeks after the initial exposure to Treponema pallidum and may present itself with multiple cutaneous expression.[1] Here, we report a rare secondary syphilis case with erythema multiforme (EM)-like skin lesions.

A 45-year-old Japanese woman presented with a 20-day history of pruritic eruptions. She was initially treated with topical corticosteroids and oral antihistamines only to find that they were ineffective and further investigation was needed. She also felt malaise for the past 20 days. The physical examination revealed maculopapular annular erythematous rashes around the abdomen, lower back, and both her upper and lower extremities, and the size of the lesion also varied between 1 and -2 cm [Figure 1]a. During the examination, mucosal involvement and palmar lesions were not observed. Lymph node swellings and feverup were not found.{Figure 1}

A skin biopsy sample obtained from her thigh, showed liquefaction degeneration in the epidermal-dermal junction and mild epidermal infiltration of small lymphocytes [Figure 1]b. Perivascular infiltration of lymphocytes and plasma cells was observed in the dermis [Figure 1]c. Serological tests showed positive for nontreponemal serological tests for syphilis (STS) and Treponema antibody. The titer for nontreponemal STS was 1:64 (normal is negative). Hepatitis B surface antigen, hepatitis C virus antibody, and human immunodeficiency virus antibody were all negative. These findings led us to diagnose the patient as secondary syphilis. She also informed us that her husband had sexual contacts with males. Based on the diagnosis, she was treated with oral antibiotics; amoxicillin 3 × 1000 mg/day for 28 days, and the titer for nontreponemal STS was measured each month to assess the efficacy of the drug and the progress of the disease. Skin lesions were significantly reduced 2 weeks after the start of treatment. The titer for nontreponemal STS went down to 1:8 7 months later.

In this report, we described a case of secondary syphilis manifesting EM-like lesions in an adult female, confirmed by serological test and skin biopsy. Secondary syphilis is also known as “the great imitator”,[2] but as far as we know there are only very few cases presenting with EM-like lesions in syphilis patients which are confirmed by nontreponemal STS titers of at least 1:32.[3] The mechanism of EM in secondary syphilis caused by T. Pallidum is rather unclear; we hypothesized that the EM-like lesions might have occurred spontaneously or evolved from the preexisting annular maculopapular lesions of early secondary syphilis. Granulysin, a cytolytic and proinflammatory molecule expressed by cytotoxic T-cells and natural killer cells, is related to EM,[4] and it is also reported that granulysin transcript expression was increased in the lesional skins of secondary syphilis patients.[5] It is highly possible that granulysin plays some roles in EM-like lesions in secondary syphilis-like this case. In conclusion, this case highlights the possibility that veneorological causes such as syphilis should also be considered when presented with EM-like skin lesions. EM cases may also happen in a secondary syphilis,[6] and may cause misdiagnosis or confusion between the two diseases.

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.

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Conflicts of interest

There are no conflicts of interest.


1Bhate C, Tajirian AL, Kapila R, Lambert WC, Schwartz RA. Secondary syphilis resembling erythema multiforme. Int J Dermatol 2010;49:1321-4.
2Brom A, Goren I, Carmel N, et al. The “great masquerader” strikes again: Secondary syphilis presentation with erythema multiforme (EM)-like lesions. Eur J Case Rep Intern Med 2014;1. [].
3Wu MC, Hsu CK, Lee JY, Chao SC, Ko WC, Sheu HM, et al. Erythema multiforme-like secondary syphilis in a HIV-positive bisexual man. Acta Derm Venereol 2010;90:647-8.
4Iwai S, Sueki H, Watanabe H, Sasaki Y, Suzuki T, Iijima M, et al. Distinguishing between erythema multiforme major and Stevens-Johnson syndrome/toxic epidermal necrolysis immunopathologically. J Dermatol 2012;39:781-6.
5Cruz AR, Ramirez LG, Zuluaga AV, Pillay A, Abreu C, Valencia CA, et al. Immune evasion and recognition of the syphilis spirochete in blood and skin of secondary syphilis patients: Two immunologically distinct compartments. PLoS Negl Trop Dis 2012;6:e1717.
6Lee JY, Lee ES. Erythema multiforme-like lesions in syphilis. Br J Dermatol 2003;149:658-60.