Granulomatous secondary syphilis: two case reports and a literature review

Historically, granulomatous inflammation has been described in association with tertiary syphilis. However, in recent years there have been increasing reports of granulomatous inflammation in patients with secondary syphilis. Here, we discuss two patients who presented with erythematous infiltrated papules and nodules and were eventually diagnosed with granulomatous secondary syphilis, with clearance of their rashes following treatment. We highlight important clues that can point clinicians and histopathologists toward a diagnosis of syphilis instead of differential diagnoses such as leprosy in reaction, cutaneous histiocytosis and lymphoma. Furthermore, after performing a literature review and from our own experiences, we wish to highlight that granulomatous syphilis is often palmoplantar-sparing and its presence may not necessarily be a feature of immunocompromised states, such as HIV infection. In this increasingly connected world, the recognition of an atypical presentation of an age-old disease in patients with different skin types must be underscored by close clinicopathological correlations.