Monthly Diagnostic Quiz

Clinical Data (Figs. 16.1, 16.2, and 16.3)

• A 42 YO patient.
• Presented with a non-itchy, slightly scaly maculopapular rash for two months.
• The affected areas included the trunk, extremities, and palms.
• Associated symptoms included fever, myalgia, and arthralgia.
• The patient was given steroid therapy in another clinic but showed no response.
• He disclosed a history of extramarital relationships.
• There was no history of drug intake before rash appearance.

Biopsy Findings (Figs. 16.4, 16.5, 16.6, and 16.7)

Biopsy of the skin rash revealed the following features:

• Psoriasiform epidermal hyperplasia and focal spongiosis.
• Focal vacuolar degeneration at the dermal-epidermal junction (DEJ).
• Few exocytotic lymphocytes and polymorph nuclear neutrophils (PMNs).
• Band-like lymphohistiocytic infiltrate in the upper dermis.
• Deep perivascular lymphohistiocytic infiltrate.
• Prominent endothelial cells.

Investigations

Lab investigations:

• Serologic testing is considered the standard method of detection for all stages of the disease.
• In suspected acquired cases, the non-treponemal serology screening tests are used.
• Such tests include:
  • Venereal Disease Research Laboratory test (VDRL).
  • Rapid plasma reagin test (RPR).
  • ICE recombinant antigen test.
• The fluorescent treponemal antibody-absorption (FTA-ABS) is commonly used as a confirmatory test following positive VDRL or RPR test findings.
• FTA-ABS has a sensitivity of 84% for detecting primary infection and almost 100% sensitivity for detecting infection in other stages. Its specificity is 96%.
• Other confirmatory serological tests include:
  • Microhemagglutination assay (MHA-TP).
  • Hemagglutination (TPHA).
  • Particle agglutination (TPPA).
• Treponemal enzyme immunoassay (EIA) for immunoglobulin G (IgG) and immunoglobulin M (IgM) may be performed.

Radiological investigations:

• Imaging studies should be performed depending on the organ system involved.

Figs. 16.1 - 16.7

Fig. 16.1

Fig. 16.2

Fig. 16.3

Fig. 16.4

Fig. 16.5

Fig. 16.6

Fig. 16.7

What is the diagnosis?