The n e w e ng l a n d j o u r na l of m e dic i n e

images in clinical medicine

Lindsey R. Baden, M.D., Editor

Annular Secondary Syphilis

A B

C D

Dong-Lai Ma, M.D., Ph.D.

Peking Union Medical College Hospital
Beijing, China
mdonglai@sohu.com

Sergio Vano-Galvan, M.D., Ph.D.

Ramn y Cajal Hospital
Madrid, Spain

A
previously well 34-year-old man presented with a 3-month history of multiple plaques on
his face (Panel A), groin and penis (Panel B), and legs (Panels C and D). (Additional images of the patient and
of biopsy specimens are available with the full text of this article at NEJM.org.) There was no associated fever,
malaise, headache, or arthralgia. The patient was heterosexual and reported a history of multiple unprotected sexual
encounters over the preceding 2 years. Physical examination revealed multiple violaceous papules and annular plaques
with slightly raised scaly borders scattered over the face, penis, legs, and feet. No lesions were observed on the mucosal
surfaces, palms, or soles. Neither alopecia nor lymphadenopathy was found. A biopsy specimen obtained from the patients
lower right leg revealed a lichenoid, perivascular infiltrate with numerous plasma cells and lymphocytes. Plump endo-
thelial cells lined the dilated blood vessels of the dermis. A rapid plasma reagin (RPR) test was positive, with a titer of
1:64, and a Treponema pallidum hemagglutination assay was reactive. A diagnosis of annular secondary syphilis was made.
A serologic test for infection with the human immunodeficiency virus was negative. The patient reported no earlier his-
tory of chancres or genital ulceration. Treatment with penicillin G benzathine was initiated, and the cutaneous lesions
resolved within 2 weeks. On repeat testing over the course of a year, his RPR test was negative.
DOI: 10.1056/NEJMicm1315543
Copyright 2014 Massachusetts Medical Society.

n engl j med 371;21 nejm.org november 20, 2014 2017

The New England Journal of Medicine
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