case_images: PMC9528754_01
case_images: Cervical angiotomography showing bilateral, symmetrical and concentric internal and external carotid arteries stenosis over 70% (yellow arrows).
case_images: 1678-9946-rimtsp-64-S1678-9946202264065-gf01.jpg
case_images: PMC9528754_01_1678-9946-rimtsp-64-S1678-9946202264065-gf01.jpg
case_images: f01
case_images: The cerebral angiotomography revealed a bilateral, symmetrical and concentric internal carotid stenosis over 70% ( Figure 1 ); the brain MRI showed multiple white matter lesions consistent with acute infractions and the largest lesion was in the right centrum semiovale owing to the patient's neurological deficit.
case_images: Violaceous discoloration and necrosis on the distal feet region.
case_images: 1678-9946-rimtsp-64-S1678-9946202264065-gf02.jpg
case_images: PMC9528754_01_1678-9946-rimtsp-64-S1678-9946202264065-gf02.jpg
case_images: f02
case_images: On day 8 after admission, peripheral bluish coloration was observed in the fingers and toes with a decrease in pulse amplitude in the four limbs ( Figure 2 ).
case_images: A) Leukocytoclastic vasculitis with karyorrhexis and fibrinoid necrosis;(B) Diffuse dermal immune infiltrate predominantly composed of plasma cells and histocytes; Cutaneous vasculitis: perivascular infiltrate of polymorphonuclear neutrophils, monocytes and lymphocytes, as well as endarteritis obliterans (Hematoxylin-eosin)
case_images: 1678-9946-rimtsp-64-S1678-9946202264065-gf03.jpg
case_images: PMC9528754_01_1678-9946-rimtsp-64-S1678-9946202264065-gf03.jpg
case_images: f03
case_images: Large and medium size vessels presented endarteritis obliterans with dense plasma cell infiltration ( Figure 3 ); taken together, these histological findings suggested syphilitic vascular and skin affection; unfortunately, the Warthin-Starry stain and immunohistochemistry using anti-T. pallidum specific antibodies were not available.