Journal of Clinical and Diagnostic Research. 2017 Dec, Vol-11(12): ZJ01-ZJ02 1 1 Images in Medicine DOI: 10.7860/JCDR/2017/32730.10985 Dentistry Section Manifestation of Primary Syphilis in Two Extragenital Regions JOÃO PAULO DE CARLI 1 , SILAS ANTONIO JUVENCIO DE FREITAS FILHO 2 , LUIZ RENATO PARANHOS 3 , GISELE ROVANI 4 , MATEUS ERICSON FLORES 5 Keywords: Biopsy, Diagnosis, Face, Infection A 52-year-old male patient, heterosexual, was referred to the Department of Stomatology at Passo Fundo University, Brazil, complaining of an ulcer in the upper lip. According to the patient, the lesion appeared spontaneously in the upper lip and evolved during 14 days. Simultaneously, a second ulcer on the nose also appeared. No history of facial trauma was reported. The patient stated that he worked as a farmer, constantly exposed to sunlight. Clinically, both ulcers presented with indurated borders. They measured 1.2 cm (center of the upper lip) and 5 mm (tip of the nose) [Table/Fig-1a]. In addition, the surrounding mucosa of the lip ulcer was normal, but the skin around the nose ulcer was erythematous. There was no increase in local temperature and the patient reported no pain on palpation. Intraorally, no lesions were observed. Cervical lymph nodes were not altered. The clinical hypothesis included actinic cheilitis, squamous cell carcinoma and bacterial or fungal infections. Incisional biopsy was performed [Table/Fig-1b]. The histopathological analysis revealed a non-specific ulceration covered by serofibrinous exudates, intense subjacent mononuclear inflammatory infiltrate and granulomatous formation [Table/Fig-2]. Venereal Disease Research Laboratory (VDRL) test was requested and resulted positive for syphilis with a titer of 1:64. The patient was treated with a single dose of Benzathine penicilin G (2.4 million units) administered intramuscularly. Within a follow up of 18 months, the titer decreased to 1:4 and clinically the appearance of the lip and nose were normal after treatment [Table/Fig-3]. Syphilis is a complex infectious disease cause by the Treponema pallidum [1]. Over the last decade, this disease became highly prevalent worldwide, especially in North America, Europe and China [2]. Diagnosing syphilis is a challenging task when oral and multiple extragenital lesions are detected [2]. Skin and mucosal lesions develop after loss of integrity of the epithelium caused by abrasions due to oral sex [3]. The diagnostic hypothesis considered in this case were based on the clinical aspects of the lesions. Knowing the clinical manifestation of syphilis is essential to guarantee optimal diagnosis of dermatologic and oral lesions. Differential diagnosis for perioral lesions must include primary tuberculosis, non-tuberculous mycobacterial infection, cutaneous leishmaniasis, cat-scratch disease [Table/Fig-1]: a) Ulcer at the apex of the nose with surrounding erythematous skin and in the upper lip without changes around; b) Incisional biopsy of the upper lip. [Table/Fig-3]: The appearance of the upper lip and nose were normal after treatment of 18 months. [Table/Fig-2]: Histopathological analysis; a) Non-specific ulceration covered by serofibrinous exudates, intense subjacent mononuclear inflammatory infiltrate and granulomatous formation (100x, H&E staining); b,c) Chronic granulomatous inflammation (B: 100x, C: 400x, H&E staining).