Case for Diagnosis
A Facial Plaque and Nodules on the Scalp
Placa facial y nódulos en cuero cabelludo
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Flores-Terry, M.P. Cortina de la Calle, C. Ramos-Rodríguez, F. Martín-Dávila" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M.Á." "apellidos" => "Flores-Terry" "email" => array:1 [ 0 => "miguelterry85@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.P. Cortina de la" "apellidos" => "Calle" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "C." "apellidos" => "Ramos-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "F." "apellidos" => "Martín-Dávila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa facial y nódulos en cuero cabelludo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 697 "Ancho" => 2333 "Tamanyo" => 416139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, hematoxylin–eosin, original magnification ×10. B, hematoxylin-eosin, original magnification ×40.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Medical History</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 54-year-old woman with no relevant past history was referred to us with a facial lesion and scalp nodules of 3 weeks’ duration. She also had holocranial headache. There were no other clinical manifestations. She reported having engaged in risky sexual activity in the preceding months. Physical examination revealed a lesion with a diameter of 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.8<span class="elsevierStyleHsp" style=""></span>cm and a “granulomatous” appearance in the chin area (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and 2 subcutaneous nodular lesions, each measuring approximately 1<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>cm, in the frontal and occipital region. There was no occipital hair loss. The regional lymph nodes were not enlarged on palpation and no other mucocutaneous lesions were observed. The patient denied previous lesions in other areas. The results of the blood tests were leukocytes, 9600/μL (normal range, 4-10); segmented, 5900/μL (1.3-7.5); erythrocyte sedimentation rate, 57<span class="elsevierStyleHsp" style=""></span>mm (1-20); ultrasensitive C-reactive protein, 3.04<span class="elsevierStyleHsp" style=""></span>mg/dL (0-0.5); aspartate aminotransferase, 50<span class="elsevierStyleHsp" style=""></span>IU/L (6-31); alanine aminotransferase, 48<span class="elsevierStyleHsp" style=""></span>IU/L (7-40); and gamma-glutamyl transferase, 70<span class="elsevierStyleHsp" style=""></span>IU/L (1-30). Skin biopsy of the facial plaque and 1 of the subcutaneous scalp nodules showed a lymphohistiocytic inflammatory infiltrate in the dermis forming noncaseating granulomas and accompanied by abundant plasma cells (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">What is your diagnosis?</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Nodular secondary syphilis.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Course and Treatment</span><p id="par0020" class="elsevierStylePara elsevierViewall">Cultures and stains were negative for bacteria, mycobacteria, fungi, and parasites. The serological tests for syphilis were positive for nontreponemal antibodies (rapid plasma reagin [RPR] titer, 1/8) and treponemal antibodies (Immunoblot immunoglobulin M antibodies, 4.67). Warthin-Starry staining of lesions was also positive. Serology was negative for hepatitis viruses B and C and human immunodeficiency virus. In view of the refractory headache, we decided to perform a lumbar puncture, but the VDRL test was negative. With a diagnosis of secondary syphilis, we initiated treatment with a single dose of intramuscular penicillin (2.4 million units), which resulted in complete resolution of the facial lesion and subcutaneous scalp nodules. The antibody titers also decreased 1 month after treatment. After a year of follow-up, the RPR results are negative and no new lesions have appeared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Comment</span><p id="par0025" class="elsevierStylePara elsevierViewall">Syphilis is an acute and chronic disease caused by the bacterium <span class="elsevierStyleItalic">Treponema pallidum</span>. It is mostly a sexually transmitted disease and its incidence has increased over the last decade. There are 4 phases of disease with varying levels of activity and infection: primary, secondary, latent, and tertiary. Syphilis is known as the <span class="elsevierStyleItalic">great mimicker</span> as it has a broad spectrum of clinical and histologic presentations.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Secondary syphilis generally develops 3 to 10 weeks after primary infection due to the hematogenous and/or lymphatic spread of spirochetes.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2,3</span></a> It is characterized by recurrent disease and presents with mucocutaneous lesions and systemic manifestations, which may include focal neurological alterations, such as cephalea due to meningeal irritation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Primary syphilis lesions are often not evident and clinical manifestations may only be noticed at a later stage of infection, as occurred in our case.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Nodular lesions are rare in syphilis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,3</span></a> Histologically, cutaneous lesions can simulate granulomatous diseases, such as sarcoidosis, which is a rare histopathologic manifestation of syphilis.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,4</span></a> Apart from inflammatory granulomatous diseases, the differential diagnosis should include leprosy, cutaneous leishmaniasis, mycobacterial infections, foreign body granulomas, and drug-induced granulomatous reactions, among others.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We have presented a new case of nodular secondary syphilis that presented with a granulomatous facial lesion and subcutaneous nodules.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Medical History" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical Course and Treatment" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Comment" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Flores-Terry MÁ, Calle MPCdl, Ramos-Rodríguez C, Martín-Dávila F. Placa facial y nódulos en cuero cabelludo. Actas Dermosifiliogr. 2018;109:441–442.</p>" ] ] "multimedia" => array:2 [ 0 => array:6 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 781 "Ancho" => 800 "Tamanyo" => 111628 ] ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 697 "Ancho" => 2333 "Tamanyo" => 416139 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, hematoxylin–eosin, original magnification ×10. B, hematoxylin-eosin, original magnification ×40.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Papulonodular secondary syphilis in a 52-year-old non-HIV heterosexual patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "V. Breznik" 1 => "M. Potocnik" 2 => "J. Miljković" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Dermatovenerol Alp Pannonica Adriat" "fecha" => "2010" "volumen" => "19" "paginaInicial" => "27" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21390478" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sexually transmitted infections" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Stary" 1 => "G. Stary" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "Dermatology." "edicion" => "3<span class="elsevierStyleHsp" style=""></span>rd edn" "serieFecha" => "2012" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nodular secondary syphilis in a woman" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Glatz" 1 => "Y. Achermann" 2 => "K. Kerl" 3 => "P.P. Bosshard" 4 => "A. Cozzio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bcr-2013-009130" "Revista" => array:3 [ "tituloSerie" => "BMJ Case Rep" "fecha" => "2013" "paginaInicial" => "8" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nodular secondary syphilis with associated granulomatous inflammation: Case report and literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Rysgaard" 1 => "E. Alexander" 2 => "B.L. Swick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/cup.12293" "Revista" => array:6 [ "tituloSerie" => "J Cutan Pathol" "fecha" => "2014" "volumen" => "41" "paginaInicial" => "370" "paginaFinal" => "379" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24447075" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010900000005/v1_201806040407/S1578219018301203/v1_201806040407/en/main.assets" "Apartado" => array:4 [ "identificador" => "6154" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case for Diagnosis" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010900000005/v1_201806040407/S1578219018301203/v1_201806040407/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219018301203?idApp=UINPBA000044" ]
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| 2024 Mayo | 74 | 26 | 100 |
| 2024 Abril | 76 | 24 | 100 |
| 2024 Marzo | 70 | 33 | 103 |
| 2024 Febrero | 64 | 22 | 86 |
| 2024 Enero | 75 | 24 | 99 |
| 2023 Diciembre | 78 | 18 | 96 |
| 2023 Noviembre | 127 | 25 | 152 |
| 2023 Octubre | 79 | 17 | 96 |
| 2023 Septiembre | 64 | 31 | 95 |
| 2023 Agosto | 42 | 16 | 58 |
| 2023 Julio | 66 | 37 | 103 |
| 2023 Junio | 51 | 18 | 69 |
| 2023 Mayo | 73 | 24 | 97 |
| 2023 Abril | 57 | 24 | 81 |
| 2023 Marzo | 85 | 17 | 102 |
| 2023 Febrero | 54 | 19 | 73 |
| 2023 Enero | 59 | 27 | 86 |
| 2022 Diciembre | 69 | 45 | 114 |
| 2022 Noviembre | 54 | 35 | 89 |
| 2022 Octubre | 40 | 21 | 61 |
| 2022 Septiembre | 32 | 34 | 66 |
| 2022 Agosto | 32 | 37 | 69 |
| 2022 Julio | 36 | 32 | 68 |
| 2022 Junio | 44 | 32 | 76 |
| 2022 Mayo | 50 | 31 | 81 |
| 2022 Abril | 54 | 40 | 94 |
| 2022 Marzo | 48 | 50 | 98 |
| 2022 Febrero | 49 | 26 | 75 |
| 2022 Enero | 57 | 44 | 101 |
| 2021 Diciembre | 52 | 41 | 93 |
| 2021 Noviembre | 73 | 43 | 116 |
| 2021 Octubre | 41 | 52 | 93 |
| 2021 Septiembre | 37 | 40 | 77 |
| 2021 Agosto | 42 | 34 | 76 |
| 2021 Julio | 65 | 24 | 89 |
| 2021 Junio | 106 | 39 | 145 |
| 2021 Mayo | 126 | 43 | 169 |
| 2021 Abril | 95 | 69 | 164 |
| 2021 Marzo | 51 | 30 | 81 |
| 2021 Febrero | 37 | 24 | 61 |
| 2021 Enero | 35 | 16 | 51 |
| 2020 Diciembre | 22 | 17 | 39 |
| 2020 Noviembre | 31 | 25 | 56 |
| 2020 Octubre | 25 | 10 | 35 |
| 2020 Septiembre | 37 | 10 | 47 |
| 2020 Agosto | 31 | 13 | 44 |
| 2020 Julio | 24 | 14 | 38 |
| 2020 Junio | 33 | 29 | 62 |
| 2020 Mayo | 28 | 19 | 47 |
| 2020 Abril | 22 | 17 | 39 |
| 2020 Marzo | 27 | 21 | 48 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 4 | 0 | 4 |
| 2019 Noviembre | 2 | 0 | 2 |
| 2019 Septiembre | 4 | 0 | 4 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 4 | 0 | 4 |
| 2019 Mayo | 4 | 0 | 4 |
| 2019 Abril | 2 | 0 | 2 |
| 2019 Marzo | 2 | 0 | 2 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 5 | 0 | 5 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 2 | 0 | 2 |
| 2018 Julio | 3 | 0 | 3 |
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