Chest Infections |

The Great Imitator Gets Us Again (Multiple Pulmonary Nodules in Syphilis) FREE TO VIEW

Manu Kaushal, MD; Asma Azimi, MD; Mark Wewers, MD; Matthew Exline, MD
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Select Speciality Hospital, Columbus, OH

Chest. 2014;146(4_MeetingAbstracts):129A. doi:10.1378/chest.1995108
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SESSION TITLE: Infectious Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The differential of multiple pulmonary nodules is extensive and includes malignancy, lymphoproliferative disorders, autoimmue disease, and many infectious etiologies. We report a case of pulmonary involvement in an HIV-negative male smoker with previously undiagnosed syphilis presenting with multiple pulmonary nodules.

CASE PRESENTATION: 52 year-old male presented with 2 weeks of headache, blurry vision, dyspnea on exertion, productive cough, fever, night sweats and weight loss. Initial laboratory studies and chest x-ray were unremarkable. He was treated with 7 days of levofloxacin for a presumed upper respiratory infection; however his symptoms did not resolve and he was subsequently admitted to the hospital. On admission, physical examination revealed a diffuse maculo-papular rash from trunk to the lower extremities, inguinal lymphadenopathy, nuchal rigidity and decreased breath sounds at the bases. Basic hematologic and metabolic studies were unremarkable, except for an elevated ESR. The patient’s HIV and quantiferon were negative. Serum rapid plasma regain (RPR) was elevated at 1:128 CT of the chest and abdomen demonstrated bilateral pulmonary nodules with small pleural effusions and an isolated enlarged inguinal lymph node. Bronchoscopically obtained fungal, and bacterial cultures were negative. A lumbar puncture yielded CSF reactive for FTA-ABS. The diagnosis of tertiary syphilis was made and the patient was started on IM benzathine penicillin. With clinical improvement the patient was subsequently discharged from the hospital. Repeat CT chest, six weeks later, showed resolution of the pulmonary nodules and pleural effusion

DISCUSSION: The incidence of pulmonary involvement in patients with syphilis has significantly reduced in the post-antibiotic era. Radiographic pulmonary syphilis can present as consolidation, solitary and multiple pulmonary nodules, pleural effusion, or infiltrates. Diagnosis of pulmonary syphilis is based on an exam and serology and subsequent clinical and radiographic improvement after initiation of anti-treponemal therapy2

CONCLUSIONS: Clinicians today should consider gummatous syphilis as a differential possibility when approaching patients with a pulmonary lesion with rash. Mindfulness of this uncommon disease could spare your patient unnecessary and invasive diagnostic testing

Reference #1: David G et al. Secondary pul­monary syphilis: Clin Infect Dis 2006;42:e11-e15.

Reference #2: Coleman et al. Secondary syphilis with pulmonary involvement West J Med. 1983 Jun;138(6):875-8

DISCLOSURE: The following authors have nothing to disclose: Manu Kaushal, Asma Azimi, Mark Wewers, Matthew Exline

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