syphilis ,  the great imitator , is among the most fascinating of skin disease . it may present to the dermatologist as a sexually acquired , contagious disease or as a congenitally acquired infection . syphilis can be transmitted by blood transfusion , but it is very rare now and in this condition , no primary lesion appears . a 28-year - old unmarried male , office worker , presented to the skin , v.d . and leprosy department with a grayish white painless plaque on the left side of the lower lip for last 8 months and multiple papulosquamous non - pruritic lesions all over the body including palm and sole . there was history of transfusion of 3 u of stored blood in to the patient for severe anemia 1 year back , in a local nursing home . on examination , lip lesion was grayish white in color , oval in shape and size was about 4 cm in diameter , soft and non - tender [ figure 1 ] . there was generalized lymphadenopathy and lymph nodes were palpable , mobile , non - tender and rubbery . there were also multiple papulosquamous non - pruritic lesions all over the body including trunk [ figure 2 ] , upper and lower limbs , palms and soles but sparing oral mucosa and the genital . lesion of secondary syphilis - flat papule ( condyloma lata ) on lip lesions of secondary syphilis - papulosquamous lesions on trunk hematological examination showed moderate anemia ( 8.2 gm% ) and all biochemical parameters were within normal range . serological tests for syphilis were positive ( vdrl in 1:32 dilution and reactive tpha ) and elisa for hiv-1 and 2 were negative . incisional biopsy of the lip lesion was sent for histopathological study , which showed dense infiltration of plasma cells and few lymphocytes in the dermis , in and around blood vessels in the form of perivasculitis and intimal proliferation in few of the arteries and veins ( endarteritis obliterans ) [ figure 3 ] . then patient was put on oral azithromycin 1 gm stat and doxycycline 100 mg twice daily and partial regression of lesion was observed after nearly 3 weeks of treatment . histopathology of lip lesion(condyloma lata ) showing plasma cell infiltration in dermis and endarteritis obliterance ( h and e stain 400 ) syphilis is a chronic disease with a waxing and waning course , the manifestations of which have been described for centuries . the rate of primary and secondary syphilis , the most infectious stages of the disease decreased throughout the 1990s and in 2000 reached an all time low . the primary mode of transmission is by sexual contact , and the next most common is transfer across the placenta . kissing , blood transfusion and accidental inoculation have also been reported as routes of transmission , but are of minor importance today . the risk of transmission through blood is negligible due to improved donor selection , uniform serological testing of all blood donor , and a shift from transfusion of fresh blood to transfusion of refrigerated blood components . transmission via blood products is nonetheless theoretically possible since organism may survive for up to 5 days in refrigerated blood . needle sharing probably does not play a significant role in syphilis , but remains unclear . the secondary stage is characterized by a polymorphic rash , lymphadenopathy and other systemic manifestations . the tertiary stage is the most destructive and is marked by cardiovascular and neurologic sequelae and gummatous involvement of any organ system . our patient presented with lesions of secondary syphilis including soft , non - tender plaque on the left side of lower lip , papulosqumaous lesions on the trunk , palms and soles and lymhadenopathy . the confirmed diagnosis of primary , secondary or early congenital syphilis are made by demonstration of organism by dark ground microscopy . serological test for syphilis include vdrl , t. pallidum immobilization test , fluorescent treponemal antibody absorption(fta - abs ) test , t. pallidum hemagglutination assay ( tpha ) test and eia ( treponemal enzyme immunoassay ) test.[811 ] in this case vdrl and tpha tests were reactive . the characteristic histopathological findings of syphilis are perivascular infiltration of plasma cells and lymphocytes and intimal proliferation of both arteries and veins ( endarteritis obliterans ) , which was seen in the biopsy of lip lesion of our case . the differential diagnosis of our case were chancre , squamous cell carcinoma lip , lichen planus , actinic granuloma , leukoplakia , psoriasis , drug eruption and graft versus host disease . theoretically , the possibility of chancre of lip could not be ruled out but strongly denied of any type of sexual contact by the patient and history of blood transfusion indicate syphilis d emblee . many antibiotics , with notable exceptions of the aminoglycosides and sulphonamides , have some treponemicidal activity . benzathine penicillin is the recommended first - line therapy for syphilis . in patients who are hypersensitive to penicillin , regimens based on tetracycline , doxycycline , erythromycin , azithromycin , ceftriaxone and chloramphenical have all been used . the patient in this case showed hypersensitivity to penicillin so he was put on azithromycin 1 gm single dose and doxycyclin 100 mg twice daily and he had been responding to it .