Got PLEVA?

If you attended ASDP this year, this case was a poster presented by my colleague Roy King.  A young adult man presented with a history of prior treatment for tinea on the face, that did not improve with therapy.  He later developed multiple crusted scaly papules on his trunk and extremities. The biopsy from the arm showed parakeratosis, crust, interface changes with scattered necrotic keratinocytes in the basal and spinous layers of the epidermis.  The superficial dermis showed an interface and perivascular infiltrate of primarily small lymphocytes with few eosinophils, no plasma cells.  These changes all seem to point to pityriasis lichenoides et varioliformis acuta (PLEVA).  There was some clinical suspicion for secondary syphilis and so the anti-treponemal immunostain was performed to be certain.  Low and behold it was loaded with spirochetes.  Nothing ground breaking here, but since syphilis appears on the rise, just something to keep in mind when you’re staring down a supposed case of pityriasis lichenoides.  Treponema pallidum is no friend to the dermatopathologist, or anyone for that matter.

South Med J. 2007 Dec;100(12):1221-2. Papulonecrotic eruption in a 44-year-old-man. Jacobson MA, Pollack RB, Maize JC Jr.

J Coll Physicians Surg Pak. 2007 Nov;17(11):689-90. Secondary syphilis lesions resembling pityriasis lichenoides. Dar NR, Ali L, Nawaz MA, Mirza IA.

Br J Dermatol. 1975 Jul;93(1):53-61. Secondary syphilis: a clinico-pathological review. Abell E, Marks R, Jones EW.

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2 responses to “Got PLEVA?

  1. Very instructive case! Syphillis without plasma cells. Unless the clinician gives you a good history and raises syphillis in the differential possibilities it must be very difficult for the pathologist to know when to do these anti treponymal stains. An accompanying clinical photograph would be very useful in cases like this.

  2. Thanks Ian. You’re right, I apologize for the lack of a good clinical picture. I tried to obtain one but struck out. Fortunately, the clinician called in on this one and gave a nice history. I agree, it is often difficult to know when to do the stain. I certainly have had more cases where the histologic findings were suspicious for syphilis but the immunostain was negative.

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