1. Case No. 1 Kunkanit Suntipraron, M.D. Vesarat Wessagowit, M.D., Ph.D.

2. Present illness: 2 weeks: minimally painful multiple localized erythematous centrally necrotic ulcerated nodules under his nostrils and on his chin, jaw, neck and shoulders. He denied a history of fever or joint pain. Past history: He denies any history of underlying disease. He denies history of IVDU

3. Dermatological examination: There were multiple localized erythematous centrally ulceronecrotic nodules with lamellar crusting at nostrils, chin, jaw, neck, shoulders and both arms. Oral: oral ulcer not seen

6. Finding multiple localized erythematous centrally necrotic ulcerated nodules under his nostrils and on his chin, jaw, neck and shoulders and both arms

7. infection non infection - penicillosis - histoplasmosis - cryptococcosis - molluscum contagiosum - pyoderma gangrenosum - vasculitis ulcer - cutaneous lymphoma - cryoglobulinemia

8. infection non infection - penicillosis - histoplasmosis - cryptococcosis - molluscum contagiosum - pyoderma gangrenosum - vasculitis ulcer - cutaneous lymphoma - cryoglobulinemia

9. infection - penicillosis - histoplasmosis - cryptococcosis - molluscum contagiosum

10. infection - penicillosis - histoplasmosis - cryptococcosis - molluscum contagiosum

11. Treatment (first visit) Dicloxacillin (500) 1 tab oral qid ac. ASAP nano silver apply at lesion

14. Histopathology

15. H&E 4x

16. H&E 20x

18. H&E 40x

19. H&E 60x

20. Finding multiple localized erythematous centrally necrotic ulcerated nodules under his nostrils and on his chin, jaw, neck shoulders and both arms histopathology shown pseudoepitheliomatous hyperplasia with mix cell infiltration including plasma cell anti HIV: negative

21. What is your diagnosis?

22. Investigation RPR: positive 1:32 TPHA: positive

23. H&E 20x

24. silver stain

25. Jaime Eduardo Calonje, M.D.; Dermpath Diagnotics, St John’s Institute of Dermatology London, UK

26. Finding multiple localized erythematous centrally necrotic ulcerated nodules under his nostrils and on his chin, jaw, neck and shoulders and also multiple localized erythematous patch at palmar of both hands histopathology shown pseudoepitheliomatous hyperplasia with mix cell infiltrate including plasma cell anti HIV: negative serology for syphilis are positive Immunohistochemistry for Treponemal: positive

27. 1% agarose gel PCR Patient negative control

28. Diagnosis Lues maligna

29. lues maligna (malignant syphilis) severe form of secondary syphilis spontaneous resolution increasing the incidence for the past few decades following the rise in prevalence of HIV

30. Diagnosis criteria for lues maligna compatible gross and microscopic morphology high titer of antibodies in the serologic test of syphilis excellent response to antibiotic therapy and Jarisch Herxheimer reaction following treatment. Text Fisher DA, et al. Lues maligna. Arch Dermatol 1969; 99: 70–73.

31. Diagnosis criteria for lues maligna compatible gross and microscopic morphology high titer of antibodies in the serologic test of syphilis excellent response to antibiotic therapy and Jarisch Herxheimer reaction following treatment. Fisher DA, et al. Lues maligna. Arch Dermatol 1969; 99: 70–73. Cripps J. D, et al. a case of syphilis malignant and negative serology. Arch Derm 1969;100:122-124.

32. Diagnosis criteria for lues maligna compatible gross and microscopic morphology high titer of antibodies in the serologic test of syphilis excellent response to antibiotic therapy and Jarisch Herxheimer reaction following treatment. RPR titer 1:32, TPHA: positive Fisher DA, et al. Lues maligna. Arch Dermatol 1969; 99: 70–73. Cripps J. D, et al. a case of syphilis malignant and negative serology. Arch Derm 1969;100:122-124.

33. Clinical cutaneous: slightly painful erythematous-violaceous papules and nodules with centrally ulcerate and cover by brown crusts area: head, neck, trunk, limbs +/- palm, oral mucosa non cutaneous: lymphadenopathy hepatosplenomegaly low grade fever, malaise risk factor HIV, DM alcoholic patient mulnutrition

34. Histology hematoxylin and eosin stain; predominant plasma cell Warthin-Starry, modified Starry or Steiner stains may help to identify spirochete

35. Treatment Benzathine penicillin 2.4 million unit intramuscular single dose closely observed for Jarisch Herxheimer reactions follow up anti HIV

36. Treatment Benzathine penicillin 2.4 million unit intramuscular single dose no Jarisch Herxheimer reactions RPR 1:32  1:8 follow up anti HIV

37. sweden

38. India

39. Australia

40. untreated course of syphilis primary chancre secondary eruption tertiary disease 10-90 days 6 weeks to 6 months period of latency 10-30 years after primary

41. Take home massage prevalence of syphilis is increasing everyday syphilis is great imitator aware of diagnosis to prevent it from developing to latent stage and tertiary stage follow up serology for HIV

42. Thank you for your attention

43. Thank you for your attention