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Chest Infections |

A 40-Year-Old Man With Pulmonary Nodules and Skin Rash

Saadah Alrajab*, MD; Berhanemeskel Nesketa, MD; Keith Payne, MD
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Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA


Chest. 2012;142(4_MeetingAbstracts):183A. doi:10.1378/chest.1387217
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Abstract

SESSION TYPE: Infectious Disease Cases II

PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM

INTRODUCTION: Secondary syphilis with pulmonary involvement is very rare. Only 11 cases were reported in the literature. We report a case of pulmonary syphilis from an area of the United States with very high syphilis incidence rates.

CASE PRESENTATION: A 40-year-old black man with past medical history of hypertension was referred to pulmonary clinic for evaluation of lung nodules. A cluster of three sub-pleural nodules in the right middle lobe (figure 1) were found incidentally during a work up for abdominal pain and pleuretic chest pain in emergency room. He reported fatigue, and occasional chest pain. He reports appearance of skin rash on his left shin few months before his current presentation. His exam was unremarkable except for a large area on his left leg with raised, hyperpigmented, plaques with some overlying scales (figure 2). The rash worsened despite his primary care physician's treatment with topical steroids. He is an active smoker with 15 pack-year history. A PET scan showed intense FDG nodular uptake. A CT-guided lung biopsy along with 2 transbronchial biopsies showed none-specific plasma cell infiltrate that tends to be perivascular. Skin biopsy showed intense perivascular plasma cell and psoriasiform infiltrate. CRP was mildly elevated. Blood cell count, comprehensive metabolic panel, HIV serology, C-ANCA, P-ANCA, Fungal serology, ACE level, Rheumatoid factor, quantiferon, and PPD skin test were all unremarkable. All cultures obtained returned negative. During follow up period his pulmonary nodules increased with new nodules forming mostly in lower lobes. Patient reported an earlier skin rash noted on his palms and soles followed a small painless penile sore that disappeared without treatment about a year ago. He also admitted an unprotected sexual contact around the same time with a male partner. Syphilis serology and IgG test were strongly positive. Lumbar puncture was negative for VDRL. Patient received 2.4 million units of benzathine penicillin weekly for 3 doses. His skin rash improved and his pulmonary nodules completely resolved 6 weeks after treatment (figure 1 and 2).

DISCUSSION: Five diagnostic criteria has been proposed for pulmonary syphilis: 1- historical and physical findings typical of secondary syphilis; 2- serologic test results positive for syphilis; 3- pulmonary abnormalities seen radiographically with or without associated pulmonary symptoms or signs; 4- exclusion of other forms of pulmonary disease and 5- therapeutic response of radiologic findings to antisyphilitic therapy (1). All of these criteria were met in our case.

CONCLUSIONS: Pulmonary syphilis should be considered in the differential diagnosis of pulmonary nodules in high risk patients from endemic areas.

1) Coleman DL , McPhee SJ , Ross TF , Naughton JL . Secondary syphilis with pulmonary involvement . West J Med .1983 ; 138 ( 6 ): 875 - 878 .

DISCLOSURE: The following authors have nothing to disclose: Saadah Alrajab, Berhanemeskel Nesketa, Keith Payne

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Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA

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