The Great Imitator

Know syphilis in all its manifestations and relations,
and all other things clinical will be added unto you.”
Sir William Osler

Henry Foong, a dermatologist from Malaysia and a good friend, recently wrote me about a patient he’d seen with primary syphilis. The disease we used to call “lues” or notate with the Greek letter (sigma) is becoming more common in Malaysia, in his experience.

This reminded me of a memorable case I saw in the late winter or early spring of 1973. At the time, I was a first year of dermatology residency at New York University. I was not a happy camper. I was tired of New York City having gone to college and medical school there and the mercantile mindset of the faculty and my fellow residents grated on me. This was one of the best dermatology programs of the country but, for me, it was an unpleasant place to work.

The wards on the public hospital, Bellevue, were a different story. Here, most of our patients were poor and some were destitute. We saw many homeless patients who in those days were called Bowery bums. One day, I admitted a sick, emaciated woman whose skin was covered with scaly plaques. They measured 4 to 8 cm in diameter and under the scale the skin looked reddish. The lesions covered most of her body. This looked like psoriasis, but even to my untrained first year resident’s eyes something was peculiar.

So what does a dermatologist do when he wants to make diagnosis? He does a biopsy. Two to three days later the results came back. The specimen was loaded with plasma cells and a diagnosis of secondary syphilis was made. The STS drawn to confirm the diagnosis was strongly positive.

A few days later the chief of the dermatology department was scheduled to make rounds on our service. Each week we presented our most challenging and interesting cases to him. In those days, the residents ran Bellevue Hospital. This was in the early days of Medicare and Medicaid and the patients were only soon once a week (if that) by senior doctors. The dermatologic wards of Bellevue were a fascinating place to work as many of the patients had advanced pathology and we were free to treat them according to our judgement.

My senior resident and I decided to present this new case to the chief of dermatology as if we had not yet made the diagnosis. We arranged to have a medical student receive a phone call from the lab just as this eminent physician finished examining the unfortunate woman. There he was, a haughty Germanic chief of service in a starched white coat. With great interest, he palpated the woman’s skin with his bare hands and was clearly uncertain about the diagnosis. He suggested psoriasis, malnutrition, and possibly lymphoma. Syphilis was not his differential diagnosis.

The phone call came in; the student reported the lab showed the serological test for syphilis was strongly positive.

Our renowned department head hastily excused himself and made a beeline to the nearest sink where he vigorously scrubbed his hands. I remember biting my lip so that I would not laugh. I don’t recall much else about this case but it was a teachable moment almost 40 years ago. In those days, I didn’t carry a camera nor did I think about writing cases up for the literature. What a shame!

We saw a lot of syphilis and other venereal diseases at Bellevue. This poor homeless woman was perhaps my most memorable.


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About David Elpern

The Online Journal of Community and Person-Centered Dermatology (OJCPCD) is a free, full text, open-access, online publication that addresses all aspects of skin disease that concern patients, their families, and practitioners. ​It was founded in 2012 by Dr. David J. Elpern, M.D. in Williamstown, MA. with technical help from Inez Tan.

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