Review Question - QID 214999

This patient presents with difficulty walking from loss of lower extremity proprioception, and pupils that constrict to accommodation only (e.g., not to light), both features of chronic untreated syphilis. A classic skin manifestation of late tertiary syphilis is the "gumma," a granulomatous benign growth with ulceration.

Syphilis is caused by the spirochete bacterium Treponema pallidum, often first presenting as a painless genital ulcer known as a “chancre,” which when left untreated can lead to systemic infection to the skin (secondary syphilis) and eventually the vasculature/internal organs (tertiary syphilis). Central nervous system manifestations (neurosyphilis) involve degeneration of the spinal posterior columns resulting in impaired lower extremity proprioception and uncoordinated gait (termed “tabes dorsalis"), and degeneration of the rostral midbrain which disrupts the pupillary light reflex and spares the pupillary accommodation reflex (termed the “Argyll-Robertson pupil"). Gummas occur in late untreated tertiary syphilis and are non-cancerous, fleshy growths or ulcerations occurring in the skin (Illustration A), liver, bone, and testis. Gummas are caused by granulomatous reactive inflammation around spirochetes and are described as having a rubbery texture and a necrotic core.

Illustration A shows a syphilitic gumma involving the skin of the nose and left maxillary region. In early stages, a subcutaneous nodule begins to grow and adhere to overlying skin (red arrow), eventually leading to surface ulceration often with exposure of viscous discharge (blue arrow).

Incorrect Answers:
Answer 1: Acrochorda or “skin tags” are benign growths of skin which occur in areas of increased skin friction (e.g., crease of the neck, axilla, and groin). They are discrete fleshy papules, which are often pedunculated.

Answer 3: Hidradenitis suppurativa is a chronic inflammatory condition of hair follicles and pilosebaceous glands, most commonly in intertriginous regions (e.g., groin and axilla). It presents as painful nodules that can coalesce to form chronic draining sinus tracts with malodorous discharge.

Answer 4: Molluscum contagiosum is a viral skin infection caused by poxvirus and presents as small discrete dome-shaped fleshy nodules with a classically dimpled center. The infection often presents in children and is self-limited, but disseminated lesions in an adult may be a presenting sign of human immunodeficiency virus (HIV) infection.

Answer 5: Verrucae or warts are caused by low-risk human papillomavirus (genotypes 6, 11, 42, 43, and 44), and present as soft cauliflower-like papules often on the soles (“plantar warts”) or genitals (“condyloma acuminatum”). Genital wart-like lesions also occur in secondary syphilis, which are similarly termed "condyloma lata" and present as white painless plaques in the genital region.

Bullet Summary:
"Gummas" are granulomatous skin growths with ulceration in tertiary syphilis and can present concurrently with neurosyphilis findings of difficulty walking from dorsal spinal column degeneration (“tabes dorsalis”) and lack of pupillary light reflex despite intact accommodation reflex (“Argyll-Robertson pupil”).