Syphilitic gumma is a late manifestation of tertiary syphilis and is extremely rare in early stages of infection. In its cutaneous form, it is characterized by deep, progressively enlarging nodules adherent to the skin. The central portion of these lesions tends to soften, ulcerate, and discharge purulent exudate, resembling a “gumma.” In addition to the skin, it may affect mucous membranes, bones, the cardiovascular system, and the central nervous system. The main route of syphilis transmission is sexual, through unprotected intercourse with infected individuals. In general, gummas develop 3 to 10 years after exposure. Diagnosis is based on treponemal and non-treponemal tests, complemented by imaging to assess lesion extent. Standard treatment involves penicillin G or ceftriaxone. A 29-year-old female patient, occupational safety technician, single, previously healthy, presented in July 2024 with holocranial headache associated with the onset of nodules on the scalp. VDRL was 1:32, with negative HIV serology. In August 2024, she was admitted to a tertiary hospital in Porto Alegre/RS for diagnostic investigation. Cerebrospinal fluid analysis showed 8 leukocytes/µL (92% lymphocytes, 8% neutrophils), protein 12 mg/dL, glucose 60 mg/dL, FTA-ABS reactive and VDRL nonreactive. In the same period, serum VDRL was 1:64, with another negative HIV result. Brain MRI revealed infiltrative nodular lesions in the scalp and underlying bones, predominantly in the frontal bone, left parietal bone, and right temporal bone, associated with osteolytic foci – findings suggestive of syphilitic gumma. Neurological examination was unremarkable. On physical exam, palpable nodules were observed in the frontal region of the scalp. Importantly, three months before diagnosis (March 2024), both VDRL and anti-HIV tests had been negative. During hospitalization, she was treated with intravenous penicillin G for 14 days, with progressive improvement in headache and reduction of cranial nodules, confirmed both clinically and by imaging. This report describes a rare case of gummatous manifestation in an immunocompetent patient with recent syphilis diagnosis, reinforcing the importance of clinical suspicion even in early stages of infection.
VIDOR et al. (Sun,) studied this question.