Thirty-Two-Year-Old Man With Osteolytic Skull Lesion

Figure 1: A 32-year-old man presented with a right frontal throbbing headache for 8 weeks and swelling of the right side of his scalp. The patient is sexually active with multiple male partners. His scalp examination revealed a tender area of swelling, 2 to 3 cm over the right side of the head. Serum RPR was reactive 1:64. Lumber puncture revealed pleocytosis with white blood cells of 33. The patient was started on penicillin IV for neurosyphilis.Within 24 hours, patient developed a Jarisch-Herxheimer reaction, and his scalp swelling increased in size. A and B, Skull x-ray and CT scan revealed osteolytic lesion of the calvarium (arrows). C, Magnetic resonance imaging with gadolinium revealed dural enhancement overlying the right convexity with focal areas of abnormal enhancement involving the calvariumextending into soft tissues (arrow). After 2 weeks of therapy, his scalp swelling significantly decreased and his headache completely resolved.