Persistent Nodular Rash in an Older Patient
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Case Presentation
A 62-year-old white male presented to a same-day clinic with a complaint of painless, nonpruritic maculopapular lesions on his back, chest, and shoulders. The lesions first appeared 2 weeks prior, and the patient had treated them unsuccessfully with bacitracin ointment. His past medical history was significant for Crohn’s disease, hyperlipidemia, a cerebrovascular accident (CVA), and recurrent methicillin-resistant Staphylococcus aureus (MRSA) furunculosis. Overall, his medical problems were well controlled, and he was compliant with his care. His medications included simvastatin and aspirin, which he had been taking for years. He denied insect exposure and use of new detergents, soaps, lotions, or other skin irritants. Of note, the patient was a wrestling coach and himself a competitive wrestler.
Physical examination revealed a muscular, healthy-appearing white male. He had diffuse, erythematous, scaling papular and nodular lesions spread over his back and chest. A wound culture was sent to the lab and came back with light growth of S. aureus, and he was started on clindamycin for presumed MRSA folliculitis.
The patient returned for follow-up 10 days later. The lesions had become more diffuse, spreading to his palms, and still nonpruritic and painless (Figures 1, 2, and 3). Upon further questioning it was discovered that the patient had had syphilis in 1982 and had been treated successfully. He had additional post-exposure negative rapid plasma reagin (RPR) tests in 2001 and 2002. He denied any genital ulcer disease. He was sexually active with a male partner, and he had never had a human immunodeficiency virus (HIV) test.
Discussion
Due to the patient actively wrestling and his history of MRSA skin infection, the initial differential diagnosis of the lesions included folliculitis, scabies, tinea corporis, and contact dermatitis. Pityriasis rosea, the rash of primary HIV, cutaneous lymphoma, and an unusual presentation of secondary syphilis were also considered (Table).
A folliculitic infection should have responded to clindamycin, even if caused by MRSA, and would not have spread to the palms. Scabies more characteristically would be found in the interdigital webs and would be intensely pruritic. Tinea corporis lesions are sharply demarcated plaques with overlying scale. They also do not characteristically occur on the palms. Contact dermatitis is an inflammatory reaction secondary to allergen exposure and is usually pruritic or tender. This patient denied any known allergen exposures. Pityriasis rosea usually begins with a “herald patch,” then the fine-scaled papules erupt in a characteristic “Christmas tree” pattern. The rash of pityriasis is often pruritic and rarely involves the palms. The rash of acute HIV could not be ruled out. It can present in many ways: diffuse morbilliform rashes with macules and papules, ulcerated lesions, and vesicular and pustular exanthems have been reported. Cutaneous lymphoma presents as randomly distributed, sharply demarcated erythematous plaques. The lesions can be scaling or nonscaling and rarely occur on the palms.
Currently, screening for syphilis has an “A” recommendation from the U.S. Preventive Services Task Force (USPSTF) for pregnant women and high-risk groups, which include men who have sex with men (MSM).1 This recommendation makes no distinction for age, underscoring the importance of assessing risk factors in all patients.
Typically, syphilis first presents as a chancre, a painless ulcer that forms about 21 days after the site’s exposure to the spirochete Treponema pallidum. This primary lesion, usually in the genital area, frequently goes unnoticed and untreated, as in the case of the case patient.
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