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Mycobacterium marinum infection in a case of psoriasis treated with antitumor necrosis factor α antibody detected by QuantiFERON®‐TB test

trunk, and extremities. Cutaneous gummata are solitary and are usually deep in the dermis. In nodular tertiary syphilis, there is a dermal lymphohistiocytic and plasma cell infiltrate with small granulomas and islands of epithelioid cells. In gummas, the infiltrate contains numerous epithelioid and multinucleated giant cells and extends throughout the dermis to the subcutaneous tissues. Our patient presented with two alopecic annular plaques. The biopsy of the scalp lesion revealed a granulomatous process with follicular involvement. In this context, our first diagnosis was cutaneous tuberculosis. However, the presence of plasma cells was more consistent with a cutaneous lesion of tertiary syphilis, which was confirmed by serology. Neurosyphilis is often referred to as the great masquerader. It may present as meningeal, meningovascular, parenchymatous, or gummatous, or may be asymptomatic. Subtle and atypical presentations of neurosyphilis now account for as many as 85.7% of cases. Patients may exhibit psychiatric symptoms such as depression, mania, or psychosis. Our patient demonstrated signs of depression without any other neurological symptoms. The CSF VDRL was negative. However, studies have shown that a CSF VDRL may be positive in as few as 30% of patients with neurosyphilis. Parenteral penicillin is the only treatment with documented efficacy in neurosyphilis. It leads to significant improvement or a full recovery. The present case demonstrates the need for dermatologists to maintain a high index of suspicion for tertiary syphilis in non-healing annular lesions and indicates the importance of CSF examination even in asymptomatic patients. Nihal Bekkali, MD Siham Oumakhir, MD Tarik Marcil, MD Mouhaine Ghfir, MD Omar Sedrati, PhD Department of Dermatology Mohammed V Military Hospital of Instruction Rabat Morocco