Syphilis is an infection known as the “great imposter” for the diversity of signs and symptoms it presents with. There has recently been an upsurge in its incidence and we must therefore be particularly alert to clinical situations, especially to special clinical situations. One example of this are patients being treated with anti-TNF alpha drugs. These drugs have many indications at present and a good safety profile, but we must remember that their main adverse effect is the increase in the risk of infections.

A Spanish male aged 30, with ankylosing spondylitis of 8 months duration, had been in treatment for 2 weeks with golimumab, and was referred to the dermatology department due to a 10-day history of salmon colored lesions on trunk, palms (Fig. 1) and soles of feet. He stated he had not taken any other drugs, except NSAIDS. He did not recall having had previous lesions on genital or oral mucosa before. During anamnesis he stated that he had had unprotected sexual relations. Due to suspicion of secondary syphilis we requested treponemal tests (FTA-ABS) and non treponemal tests (VDRL and RPR), which tested positive. The serologies for HIV and hepatitis B and C viruses tested negative. Due to the diagnosis of syphilis of indeterminate duration the patient was treated with intramuscular benzathine G penicillin, 2.4 million units, in a total of 3 separate doses for one week. Neurological examination was normal, but since the patient had been previously treated with an anti-TNF alpha agent we decided to perform lumbar puncture, requesting the PRP test, cellularity and biochemistry in cerebrospinal fluid, which resulted non pathological. Other sexually transmitted diseases were tested for, resulting in the polimerase chain reaction (PCR) as positive for Neisseria gonorrhoeae in the pharynx and the patient therefore received treatment with 250mg ceftriaxone by intramuscular route and 1g of oral azitromicin in a single dose. The patient is currently undergoing periodic clinical and serological controls, and evolution has been favourable.

Fig. 1.

Salmon-colored lesions on the soles of both feet.

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Golimumab is a recombinant human IgG1 monoclonal antibody, the mechanism of action of which consists of blocking TNF alpha. It is used in several rheumatological diseases, including rheumatoid arthritis, ankylosing spondylitis or psoriatic arthritis. As with the other anti-TNF alpha drugs, there is a well-established protocol of testing for infections and comorbidities before and during treatment. However, cases of syphilis in patients in treatment with anti-TNF alpha are rare in the literature, and there are therefore no established protocols to follow in this exceptional circumstance. Of the 5 cases described in the literature (Table 1), 2 had neurological symptoms, including emotional lability and excitability and 4 had a pathological lumbar puncture (VDRL positive or raised cellularity). In our case, despite the absence of neurological dysfunction symptoms we reached a multidisciplinary consensus to perform lumbar puncture to rule out subclinical neurological involvement, observed more commonly in immunodepressive patients. The majority of cases described were in treatment with infliximab. This is the first case of syphilis described in the literature in the context of treatment with golimumab.

Accurate diagnosis and treatment of syphilis is essential to avoid contagion and sequelae. If patients are going to receive treatment with anti-TNF alpha agents this entity should be taken into consideration and an anamnesis should be undertaken to assess factors such as unprotected sex and the number of sexual partners. Periodical skin examination is required and if risk factors exist then luetic serological tests should be requested prior to initiation of biological treatment and regularly during treatment. There is currently no well-established diagnostic and therapeutic protocol for these patients.

The authors have no conflicts of interest to declare.