Large syphilitic gumma on the face mimicking dermatitis artefacta

A 47-year-old female patient presented with a few months’ history of a painless ulcerated lesion on the face (Figure 1 A). Her medical history included paranoid schizophrenia. Clinical examination revealed a deep irregular ulcerative lesion with a raised erythematous border partially covered with a yellow granulation tissue and an eschar covering the centre of the forehead, the cheeks and the nose bridge reaching to the internal eye-corner on both sides (Figure 1 B). Based on the unclear history of the psychiatric symptoms and the isolation of Enterococcus faecalis in tissue culture, the provisional diagnosis of dermatitis artefacta was made. Other differential diagnoses included pyoderma gangrenosum and squamous cell carcinoma. The lesion progressed despite systemic and local antibiotics. Skin biopsy demonstrated granulocytic inflammatory infiltrate with numerous plasma cells and eosinophils as well as the features of obliterating endarteritis (Figures 2 A, B). The marked presence of plasma cells in the lesional biopsy prompted us to order a serum specific treponemal test (TPHA), which was reactive and the rapid plasma reagin test (RPR), which was negative. A diagnosis of the gummatous type of cutaneous tertiary syphilis was suggested. It was later discovered that the patient was diagnosed with syphilis during her pregnancy approximately 25 years ago and underwent the treatment in the form of injections, however no further medical details were obtained. There were no neurological, cardiac or ophthalmological abnormalities. The cytological and serological analysis of the cerebrospinal fluid were also negative. The patient was treated with penicillin G (24 million U/day intravenously for 14 days) and three intramuscular injections of benzathine benzylpenicillin 2.4 MU at weekly intervals. The enzymatic debridement of the necrotizing wound, topical antibiotics and synthetic wound dressing were used locally which led to a stepwise resolution of the skin lesion within 1 year (Figures 1 C, D).
Syphilis is a systemic infectious disease caused by the spirochete Treponema pallidum [1]. Due to the variety of clinical presentations, syphilis is often called “the great masquerader” of other conditions. Although syphilis has a worldwide distribution, its incidence rate in Poland has been increasing in recent years [2].
If left untreated, almost one-third of patients with primary or secondary syphilis can develop the tertiary stage of the disease [3]....


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