Cervical syphilitic lymphadenitis causing fever of unknown origin followed by rash of secondary syphilis

A computed tomography imaging showed multiple enlarged bilateral cervical lymph nodes, largest measuring 1.9 × 1.3 cm on the right and 2.0 × 1.8 cm on the left, and an enlarged supraclavicular lymph node, measuring 1.5 × 2.1 cm [Figure 1]. Histologic analysis showed a non-necrotizing granulomatous reaction with giant cell formation [Figure 2]a. Acid fast, Gomori methenamine- silver nitrate, and periodic acid-Schiff stains were negative for organisms. A skin punch biopsy revealed an acanthotic skin with focal inflamed ulcer with epidermal spongiosis and plasma cell predominant inflammation [Figure 2]b. An immunoperoxidase stain for Treponema pallidum showed numerous intraepidermal spirochetes [Figure 3]a and [Figure 3]b. Rapid plasma reagin titer was 1:128 and the patient was treated with a single intramuscular dose of benzathine penicillin G.{Figure 1}{Figure 2}{Figure 3} Syphilitic or luetic lymphadenopathy usually has features of follicular hyperplasia and often marked by medullary and interfollicular plasmacytosis.