Images in Clinical Medicine

Keratoderma Blennorrhagica

Ivan Tonna, M.R.C.P., and Robert B.S. Laing, M.D., F.R.C.P.E.

N Engl J Med 2008; 358:2160May 15, 2008

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A 55-year-old bisexual man presented with a few weeks' history of lethargy followed by the onset of a widespread nonpruritic rash that covered much of his body, including the palms (Panel A). Vesiculopustular waxy lesions consistent with keratoderma blennorrhagica were present on the soles (Panel B). Eight weeks before the onset of these symptoms, the patient had an episode of diarrhea that was associated with bleeding from the rectum. Colonoscopy at that time revealed moderate proctitis; no causative agent was identified, and the symptoms resolved without specific therapy. A rapid plasma reagin test was positive at 1:64. A Treponema pallidum agglutination test and IgG and IgM enzyme immunoassays were also positive. The patient reported having had no primary chancre. He was treated with a single dose of intramuscular benzathine penicillin, and both the rash and the keratoderma resolved. Testing for the human immunodeficiency virus was negative. Keratoderma blennorrhagica may be associated with a variety of sexually transmitted or gastrointestinal pathogens and should prompt appropriate diagnostic testing.

Ivan Tonna, M.R.C.P.
Robert B.S. Laing, M.D., F.R.C.P.E.
Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, Scotland

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