Cutaneous manifestation of late-type syphilis

History and clinical findings: A 49-year-old, otherwise healthy man presented at his dermatologist with tuberous skin changes that had be present for several weeks on head, arm and leg. These were asymptomatic, but disturbed him cosmetically. A skin biopsy was performed. Investigations: The skin biopsy showed a granulomatous inflammation with prominent plasma cells, consistent with granulomatous infiltrate. Serologic tests confirmed a Treponema pallidum-infection. In addition, the patient was tested positive for hepatitis C and HIV (CDC stage A1). The clinical neurological examination did not show any pathological findings, however, analysis of the cerebrospinal fluid revealed a mild pleocytosis, elevation of protein and the glucose quotient and a normal Treponema pallidum TPPA-antibody index. A mesaortitis was excluded. Therapy and course: We diagnosed a tertiary syphilis (stage III). The patient refused prolonged inpatient treatment with penicillin G i.v., as recommended as first-line therapy in the national guidelines for asymptomatic neurosyphilis. Therefore, after a single oral administration of 100mg prednisolone he received ceftriaxone intravenously for 14 days. The skin changes resolved. With regard to the HIV infection anti-retro-viral therapy was not yet indicated. Conclusions: In view of the increasing incidence of syphilis in Germany clinicians should consider this diagnosis when confronted with oligosymptomatic skin lesions.