A skin rash with multiple pulmonary nodules

A 37-year-old man presented with a 2-week history of fever and thoracic pain. On physical examination, he presented a nonpruritic skin rash (0.2–1-cm nontender pink papules) on the trunk (figure 1a), upper extremities, face and soles of the feet, which had developed about 2 months previously. He also had multiple palpable and painful lymph nodes. Additional history revealed that the patient had homosexual contact 3 months before the skin rash developed; a painless genital ulcer developed and then disappeared spontaneously.

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FIGURE 1

a) Photography showing skin rash on the trunk. b and c) Chest computed tomography images obtained at the level of the lower lobes showing multiple small, ill-defined nodules (arrows).

Routine blood test results were normal. Rapid plasma reagin and Venereal Disease Research Laboratory test results were positive. Computed tomography (CT) revealed multiple ill-defined pulmonary nodules, mostly in the lower lobes of the lungs (figure 1b and c). An open lung biopsy demonstrated a peribronchovascular infiltrate and alveolar spaces filled by plasmocytes and histiocytes, without necrosis. Biopsy of a skin lesion showed the same pattern. The patient's history and clinical, laboratory and histopathological findings were compatible with secondary syphilis. The patient was treated with penicillin. 8 weeks after treatment, complete regression of the skin lesions was observed and CT findings were normal.

The prevalence of syphilis has recently increased worldwide [1]. However, pulmonary involvement in secondary syphilis is extremely rare [2, 3]. To our knowledge, only seven cases of secondary syphilis with pulmonary involvement including CT findings have been published in the English-language literature. All of these cases presented with multiple pulmonary nodules. The association of pulmonary nodules with the characteristic skin lesions may aid diagnosis and the early institution of treatment.