Syphilis mimicking a metastatic tumour: a case report and review of the literature

PURPOSE: Syphilis is an infectious disease with a wide range of clinical manifestations. Diagnosis is often challenging as the symptoms of syphilis can mimic malignant or autoimmune diseases. Here, we report on a patient with tertiary syphilis mimicking a metastatic testicular tumour. METHODS: Syphilis was diagnosed by serological testing and immunohistochemistry of tissue biopsies using specific antibodies. Additionally, a comprehensive literature review was conducted using a PubMed database search to identify previously reported cases and relevant studies. RESULTS: A 57-year-old male patient developed fever, night sweats and weight loss for three months after he had been treated with glucocorticoids for lumbar disc herniation. At first presentation, physical examination was unremarkable except for cervical lymphadenopathy. FDG-PET revealed hepatic and testicular lesions suspicious for malignancy. Biopsy of the hepatic lesion was inconclusive and showed features of pseudotumourous inflammation. The orchiectomy specimen demonstrated a large inflammatory pseudotumour composed of mixed lymphoplasmacytic and granulocytic infiltrates, with no evidence of neoplasia. Serological testing yielded elevated titers of Treponema pallidum antibodies and immunohistochemistry detected high numbers of spirochaetes in the biopsies. Antibiotic treatment with ceftriaxone and benzylpenicillin led to relief of symptoms and a decline of antibody titers. Literature review identified several cases of syphilis masquerading as malignant disease, whereas a potential reactivation of syphilis under immunosuppressive therapy remains rare. CONCLUSION: This case highlights tertiary syphilis as a rare but important differential diagnosis of pseudotumorous lesions mimicking metastatic malignancy, particularly in the presence of atypical histopathology. Immunosuppression may have contributed to clinical manifestation.