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Mena Lora AJ, Braniecki M, Nasir A, Brito M. The great impostor: Lues maligna in an HIV-infected male. SAGE Open Med Case Rep 2017; 5:2050313X17731050. [PMID: 28955441 PMCID: PMC5607913 DOI: 10.1177/2050313x17731050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 08/16/2017] [Indexed: 11/15/2022] Open
Abstract
Lues maligna is a rare severe cutaneous manifestation of secondary syphilis. It is also known as malignant syphilis and ulceronodular syphilis. We report a case of a 58-year-old HIV-infected male who presented with diffuse, pruritic, non-tender, maculo-papular skin lesions, ulcerated nodules and plaques surrounded by an erythematous base. The disseminated skin lesions were at various stages and were located on his back, chest, arms and testicles. Patient had been receiving antiretroviral therapy. Laboratory studies had demonstrated CD4 lymphocyte count of 463 cells/mm3 and an undetectable HIV viral load. Workup revealed a rapid plasma reagin of 1:256 dilutions and the skin biopsy findings were compatible with syphilis. The skin lesions resolved with intramuscular penicillin. We herein describe a rare case of lues maligna in an HIV-infected patient with a preserved immune function and viral suppression. Such skin lesions can mimic fungal or mycobacterial infections and can pose a diagnostic challenge. Even in the modern era, syphilis remains the great impostor. Clinicians must be able to recognize this condition based on clinical characteristics and risk factors to diagnose and treat this condition promptly.
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Affiliation(s)
| | | | - Ayman Nasir
- Ross University School of Medicine, Miramar, FL, USA
| | - Maximo Brito
- The University of Illinois at Chicago, Chicago, IL, USA
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2
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Affiliation(s)
- Russell A Johnson
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Adam M Spivak
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
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3
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Rao AG, Swathi T, Hari S, Kolli A, Reddy UD. Malignant Syphilis in an Immunocompetent Adult Male. Indian J Dermatol 2017; 62:318-320. [PMID: 28584378 PMCID: PMC5448270 DOI: 10.4103/ijd.ijd_168_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The occurrence of malignant syphilis in an immunocompetent individual is rare. We present malignant syphilis in a 35-year-old immunocompetent male who presented with a 1-month history of noduloulcerative lesions on the torso. Examination revealed multiple pustules, nodules, and deep-seated ulcers distributed on the trunk, face, and upper and lower limbs. Characteristic morphology of lesions, positive serological tests for syphilis, characteristic histopathology, and resolution of lesions following institution of penicillin therapy confirmed the clinical diagnosis of malignant syphilis.
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Affiliation(s)
| | - T Swathi
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Sharanya Hari
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Amit Kolli
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
| | - Uday Deshmukh Reddy
- Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India
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4
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Yamashita M, Fujii Y, Ozaki K, Urano Y, Iwasa M, Nakamura S, Fujii S, Abe M, Sato Y, Yoshino T. Human immunodeficiency virus-positive secondary syphilis mimicking cutaneous T-cell lymphoma. Diagn Pathol 2015; 10:185. [PMID: 26449225 PMCID: PMC4599588 DOI: 10.1186/s13000-015-0419-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 10/01/2015] [Indexed: 12/31/2022] Open
Abstract
Malignant syphilis or lues maligna is a severe form of secondary syphilis that was commonly reported in the pre-antibiotic era, and has now reemerged with the advent of the human immunodeficiency virus (HIV) epidemic. However, the characteristic histopathological findings of malignant syphilis remain controversial. The aim of this case report was to clarify the clinical and histopathological findings of HIV-positive malignant secondary syphilis. A Japanese man in his forties complained of fever, skin lesions, headache, and myalgia without lymphadenopathy during the previous 4 weeks. The skin lesions manifested as erythematous, nonhealing, ulcerated papules scattered on his trunk, extremities, palm, and face. Although the skin lesions were suspected to be cutaneous T-cell lymphomas on histological analyses, they lacked T-cell receptor Jγ rearrangement; moreover, immunohistochemical analyses confirmed the presence of spirochetes. The patient was administered antibiotics and anti-retroviral therapy, which dramatically improved the symptoms. On the basis of these observations of the skin lesions, we finally diagnosed the patient with HIV-associated secondary syphilis that mimicked cutaneous T-cell lymphoma. The patient’s systemic CD4+ lymphocyte count was very low, and the infiltrate was almost exclusively composed of CD8+ atypical lymphocytes; therefore, the condition was easily misdiagnosed as cutaneous lymphoma. Although the abundance of plasma cells is a good indicator of malignant syphilis on skin histological analyses, in some cases, the plasma cell count may be very low. Therefore, a diagnosis of malignant secondary syphilis should be considered before making a diagnosis of primary cutaneous peripheral T-cell lymphoma or lymphoma associated with HIV infection.
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Affiliation(s)
- Michiko Yamashita
- Division of Diagnostic Pathology, Tokushima Red Cross Hospital, 103, Irinokuchi, Komatsushima-cho, Komatsushima-shi, Tokushima, 7738502, Japan.
| | - Yoshiyuki Fujii
- Division of Diagnostic Pathology, Tokushima Red Cross Hospital, 103, Irinokuchi, Komatsushima-cho, Komatsushima-shi, Tokushima, 7738502, Japan.
| | - Keiji Ozaki
- Division of Hematology, Tokushima Red Cross Hospital, Tokushima, Japan.
| | - Yoshio Urano
- Division of Dermatology, Tokushima Red Cross Hospital, Tokushima, Japan.
| | - Masami Iwasa
- Division of Hematology, Tokushima University Hospital, Tokushima, Japan.
| | - Shingen Nakamura
- Division of Hematology, Tokushima University Hospital, Tokushima, Japan.
| | - Shiro Fujii
- Division of Hematology, Tokushima University Hospital, Tokushima, Japan.
| | - Masahiro Abe
- Division of Hematology, Tokushima University Hospital, Tokushima, Japan.
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
| | - Tadashi Yoshino
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan.
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Braue J, Hagele T, Yacoub AT, Mannivanan S, Sokol L, Glass F, Greene JN. A case of rupioid syphilis masquerading as aggressive cutaneous lymphoma. Mediterr J Hematol Infect Dis 2015; 7:e2015026. [PMID: 25960854 PMCID: PMC4418386 DOI: 10.4084/mjhid.2015.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/03/2015] [Indexed: 11/08/2022] Open
Abstract
Secondary syphilis has been known since the late 19th century as the great imitator; however, some experts now regard cutaneous lymphoma as the great imitator of skin disease. Either disease, at times an equally fastidious diagnosis, has reported to mimic each other even. It is thus vital to consider these possibilities when presented with a patient demonstrating peculiar skin lesions. No other manifestation of secondary syphilis may pose such quandary as a rare case of rupioid syphilis impersonating cutaneous lymphoma. We present such a case, of a 36-year-old HIV positive male, misdiagnosed with aggressive cutaneous lymphoma, actually exhibiting rupioid syphilis thought secondary to immune reconstitution inflammatory syndrome (IRIS).
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Affiliation(s)
- Jonathan Braue
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Down Blvd, Tampa, Florida 33612-4742
| | - Thomas Hagele
- University of South Florida Morsani College of Medicine, Department of Dermatology and Cutaneous Surgery, 12901 Bruce B. Down Blvd, Tampa, Florida 33612-4742
| | | | - Suganya Mannivanan
- University of South Florida, Morsani College of Medicine, Division of Infectious Disease and International Medicine, 1 Tampa General Circle, G323, Tampa, Florida 33612-9497
| | - Lubomir Sokol
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, Florida 33612-9497
| | - Frank Glass
- Moffitt Cancer Center, Department of Cutaneous Oncology, 12902 Magnolia Drive, Tampa, Florida 33612-9497
| | - John N. Greene
- Moffitt Cancer Center, University of South Florida College of Medicine, 12902 Magnolia Drive, Tampa, Florida 33612-9497
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Abstract
Malignant syphilis is an uncommon, but not unknown, ulcerative variation of secondary syphilis. The lesions typically begin as papules, which quickly evolve to pustules and then to ulcers with elevated edges and central necrosis. It is usually, but not mandatory, found in patients with some level of immunosuppression, such as HIV patients, when the TCD4(+) cell count is >200 cells/mm(3). Despite the anxiety the lesions cause, this form of the disease has a good prognosis. The general symptoms disappear right after the beginning of treatment, and lesions disappear over a variable period. This study reports the case of a 27-year-old man who has been HIV positive for 6 years, uses antiretroviral therapy incorrectly, has a TCD4(+) cell count of 340 cells/mm(3), a VDRL of 1:128 and itchy disseminated hyperchromic maculopapular lesions with rupioid crusts compatible with malignant syphilis.
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Rajan J, Prasad PVS, Chockalingam K, Kaviarasan PK. Malignant syphilis with human immunodeficiency virus infection. Indian Dermatol Online J 2012; 2:19-22. [PMID: 23130209 PMCID: PMC3481795 DOI: 10.4103/2229-5178.79864] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Malignant syphilis or Lues maligna, commonly reported in the pre-antibiotic era, has now seen a resurgence with the advent of human immunodeficiency virus (HIV). Immunosuppression and sexual promiscuity set the stage for this deadly association of HIV and Treponema pallidum that can manifest atypically and can prove to cause diagnostic problems. We report one such case in a 30-year-old female who responded favorably to treatment with penicillin.
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Affiliation(s)
- Jiby Rajan
- Department of Dermatology, Venereology and Leprology, RMMCH, Annamalai University, Chidambaram, India
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The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol 2011; 33:433-60. [PMID: 21694502 DOI: 10.1097/dad.0b013e3181e8b587] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Syphilis has plagued mankind for centuries and is currently resurgent in the Western hemisphere. Although there has been a significant reduction of tertiary disease and recognition of facilitative interactions with human immunodeficiency virus infection, the natural history of syphilis has remained largely unchanged; thus, new strategies are required to more effectively combat this pathogen. The immunopathologic features of experimental syphilis in the rabbit; the course, stages, and pathology of human syphilis; and a comparison of human syphilis with leprosy suggest that the clinical course of syphilis and its tissue manifestations are determined by the balance between delayed-type hypersensitivity (DTH) and humoral immunity to the causative agent, Treponema pallidum. A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease. Many of the protean symptoms/appearances of secondary and tertiary human syphilis are manifestations of immune reactions that fail to clear the organism, due to a lack of recruitment and, more importantly, activation of macrophages by sensitized CD4 T cells. The Bacillus Calmette-Guerin vaccination can enhance DTH and has been shown to produce a low, but measurable, beneficial effect in the prevention of leprosy, a disease that shows a disease spectrum with characteristics in common with syphilis. In the prevention of syphilis, a potential vaccine protective against syphilis should be designed to augment the DTH response.
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Kelly JD, LeLeux TM, Citron DR, Musher DM, Giordano TP. Ulceronodular syphilis (lues maligna praecox) in a person newly diagnosed with HIV infection. BMJ Case Rep 2011; 2011:bcr.12.2010.3670. [PMID: 22689612 DOI: 10.1136/bcr.12.2010.3670] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
In this case of secondary syphilis, pustular lesions progressed rapidly to painful ulcerative lesions in a patient with early HIV infection. This rapidly progressive form of early syphilis has historically been called lues maligna praecox, a severe form of noduloulcerative secondary syphilis. Serologic tests for syphilis were positive and biopsy showed forms consistent with Treponema pallidum in the lesions. This case demonstrates how HIV infection may affect presentation and diagnosis of secondary syphilis.
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Affiliation(s)
- John D Kelly
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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[An Irishman with fever and skin lesions]. Enferm Infecc Microbiol Clin 2011; 29:152-3. [PMID: 21345526 DOI: 10.1016/j.eimc.2010.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 08/02/2010] [Accepted: 08/04/2010] [Indexed: 11/24/2022]
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Yanagisawa N, Ando M, Imamura A, Akagi K, Horiguchi SI, Suganuma A, Ajisawa A. Pathologically confirmed malignant syphilis in an HIV-infected patient. Intern Med 2011; 50:2423-6. [PMID: 22001480 DOI: 10.2169/internalmedicine.50.5605] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a case of pathologically confirmed malignant syphilis in an HIV-infected patient. Physical examinations revealed ulceronecrotic skin lesions. Skin biopsies demonstrated syphilis spirochetes on immunohistochemical stain, and syphilis serological titers were positive. Treatment with intravenous penicillin G was begun, and complete resolution of the skin lesions was observed. A rapid plasma reagin titer test performed 3 months after treatment revealed a 4-fold reduction in the titer, indicating successful treatment.
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Affiliation(s)
- Naoki Yanagisawa
- Department of Infectious Diseases, Tokyo Metropolitan Komagome Hospital, Japan.
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Pleimes M, Hartschuh W, Kutzner H, Enk A, Hartmann M. Malignant Syphilis with Ocular Involvement and Organism‐Depleted Lesions. Clin Infect Dis 2009; 48:83-5. [DOI: 10.1086/594127] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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13
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Angus J, Langan SM, Stanway A, Leach IH, Littlewood SM, English JS. The many faces of secondary syphilis: a re-emergence of an old disease. Clin Exp Dermatol 2006; 31:741-5. [PMID: 16901332 DOI: 10.1111/j.1365-2230.2006.02163.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There has been a recent dramatic re-emergence of syphilis in the UK. This article describes the varied clinical manifestations of secondary syphilis and describes the diagnosis and current guidelines for treatment, especially in association with human immunodeficiency virus infection.
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Affiliation(s)
- J Angus
- Department of Dermatology, Queen's Medical Centre, Nottingham, UK.
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14
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Affiliation(s)
- Joseph A Witkowski
- Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Abstract
This paper reports a case of malignant syphilis (man, 39 years old) in whom ultrastructural investigations of a typical nodule revealed an extremely low amount of bacteria with the characteristics of Treponema pallidum in poorly differentiated cells of the dermal infiltrate with plasma cells, stimulated lymphocytes, and neutrophils as predominating cell types. Most of the microorganisms bore signs of disintegration. Vascular changes and exocytosis were only demonstrable by light microscopy in a second nodule. Together with the high production rate of immunoglobulins and an excessive inflammatory reaction, these findings point to an aberrant biologic reaction pattern of those patients who develop malignant syphilis. Unfortunately, further investigations concerning a possible impairment of cellular immunity as supposed in the literature, had not been possible in the present case.
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