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Rosa MFDAP, Quintella LP, Ferreira LC, Cuzzi T. Immunohistochemical detection of Treponema pallidum in skin samples with clinical and histopathological correlations and Warthin-Starry staining critical analysis. An Bras Dermatol 2023; 98:480-486. [PMID: 36906465 PMCID: PMC10334320 DOI: 10.1016/j.abd.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Syphilis in its different phases may be a difficult diagnosis in clinical and histopathological grounds. OBJECTIVES The present study objectives were to evaluate the detection and tissue distribution of Treponema pallidum in skin lesions of syphilis. METHODS A blinded diagnostic accuracy study was performed with immunohistochemistry and Warthin-Starry silver staining in skin samples from patients with syphilis and other diseases. Patients attended two tertiary hospitals between 2000 and 2019. Prevalence ratios (PR) and 95% confidence intervals (95% CI) were calculated for the association between immunohistochemistry positivity and clinical-histopathological variables. RESULTS Thirty-eight patients with syphilis and their 40 biopsy specimens were included in the study. Thirty-six skin samples were used as non-syphilis controls. The Warthin-Starry technique was unable to accurately demonstrate bacteria in all samples. Immunohistochemistry showed spirochetes only in skin samples from patients with syphilis (24/40) with 60% sensitivity (95% CI 44.8‒75.2). Specificity was 100% and accuracy, 78.9% (95% CI 69.8‒88.1). Most cases had spirochetes in both dermis and epidermis and there was a high bacterial load. STUDY LIMITATIONS Correlation between immunohistochemistry and clinical or histopathological characteristics was observed but was limited statistically due to the small sample size. CONCLUSIONS Spirochetes were promptly seen in an immunohistochemistry protocol, which can contribute to the diagnosis of syphilis in skin biopsy samples. On the other hand, the Warthin-Starry technique showed to be of no practical value.
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Affiliation(s)
| | - Leonardo Pereira Quintella
- Anatomical Pathology Service, National Institute of Infectious Diseases, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - Luiz Claudio Ferreira
- Anatomical Pathology Service, National Institute of Infectious Diseases, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brazil
| | - Tullia Cuzzi
- Department of Pathology, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Harper HE, Hegde S, Fraga GR, Hall JC. Syphilis presenting as exfoliative erythroderma. Int J Dermatol 2023; 62:e221-e223. [PMID: 35393692 DOI: 10.1111/ijd.16219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Haleigh E Harper
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Siddhanth Hegde
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Garth R Fraga
- Department of Pathology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - John C Hall
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
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Yuylana C, Iswanty M, Paturusi II. Secondary syphilis mimicking tinea cruris in an HIV infected patient: a case report. Pan Afr Med J 2021; 38:133. [PMID: 33912303 PMCID: PMC8052625 DOI: 10.11604/pamj.2021.38.133.27922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Abstract
Syphilis is known as the great imitator with various clinical presentations which often lead to confusion and misdiagnosis. A 28-year-old male presented with non-pruritic and painless erythematous patches around the anus and scrotum. Initial differential diagnosis with tinea cruris. Fungal examination was negative. Serological tests for syphilis were positive and anti-HIV screening was reactive. A diagnosis of secondary syphilis was established and the patient was given intramuscular injection of 2.4 million unit of benzathine penicillin. The skin lesions improved significantly 1 week after treatment, confirming a diagnosis of secondary syphilis with HIV. Annular skin lesions in secondary syphilis are uncommon and often misleading. This case emphasizes the importance of considering secondary syphilis in the differential diagnosis of annular lesions.
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Affiliation(s)
- Cyntia Yuylana
- Department of Dermatology and Venereology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Muji Iswanty
- Department of Dermatology and Venereology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
| | - Idrianti Idrus Paturusi
- Department of Dermatology and Venereology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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Mahlangeni GM, Tod BM, Jordaan HF, Schneider JW. Clinicopathological Features of Seborrheic-Like Dermatitis in HIV-Infected Adults: A Single Institutional Descriptive Cross-Sectional Study. Am J Dermatopathol 2021; 43:27-34. [PMID: 32379092 DOI: 10.1097/dad.0000000000001670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Atypical and severe clinical presentations of seborrheic-like dermatitis (SLD) are associated with HIV infection, correlating with advanced disease or low CD4 counts. Previous studies documented histological findings characteristic of seborrheic dermatitis in HIV-positive patients. OBJECTIVE To expand current knowledge of the clinicopathological characteristics of SLD in South African HIV-seropositive individuals. METHODS This prospective study included HIV-seropositive adult patients presenting with SLD to a dermatology clinic from March 2017 to April 2018. A dermatologist established the diagnosis of SLD and the severity of the disease. Detail about antiretroviral therapy (ART), the latest CD4 count, and the viral load was retrieved from the patients' clinical records. Histopathological assessment of the patients' skin biopsies was recorded using standardized data sheets and semiquantifiable grades. RESULTS This study included 13 women and 17 men. Fifty percent of patients showed severe or very severe SLD. Six (20.0%) patients presented with erythroderma. Statistical analysis did not show a significant correlation between severity of disease and CD4 count, viral load, or ART, respectively. This study confirmed that the presence of confluent parakeratosis, necrotic keratinocytes, plasma cells, neutrophils with leukocytoclasia, and leukoexocytosis are histopathological clues to SLD occurring in HIV-seropositive patients. CONCLUSION SLD in HIV patients may present with varying clinical severity, including erythroderma. The association between the prevalence and severity of SLD with CD4 count, viral load, and ART requires further studies with larger patient populations. The presence of specific histopathological features in a skin biopsy of SLD is a clue to the diagnosis of HIV.
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Affiliation(s)
- Gcina M Mahlangeni
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa; and
| | - Bianca M Tod
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa; and
| | - Hendry Francois Jordaan
- Division of Dermatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa; and
| | - Johann W Schneider
- Division of Anatomical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Academic Hospital, Cape Town, South Africa
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Mohanlal R, Reddy DL. Spectrum of HIV-associated infectious diseases: A case series through the eyes of the histopathologist. South Afr J HIV Med 2020; 21:1087. [PMID: 32670628 PMCID: PMC7343954 DOI: 10.4102/sajhivmed.v21i1.1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/23/2020] [Indexed: 11/11/2022] Open
Abstract
Background Human immunodeficiency virus (HIV) infection increases the risk of infection by a host of other opportunistic pathogens. The clinical presentations of these co-infections in immunocompromised patients are often atypical; therefore diagnosis is delayed in the absence of investigations such as tissue biopsy. Infection may involve sites that are difficult to access for biopsy and, as a consequence, there is limited diagnostic tissue available for analysis. The histopathologist, aided by ancillary tests, is relied upon to make a timeous and accurate diagnosis. Objectives To illustrate key histological features of HIV-associated infectious diseases encountered in a histopathology laboratory and to highlight, with the aid of literature, the relevance of histopathology in diagnosis. Method A retrospective descriptive case series of biopsies histologically diagnosed with HIV-associated infectious diseases over four years (2015–2019) was performed at the Chris Hani Baragwanath Academic Hospital National Health Laboratory Services Histopathology department. These cases have been photographed to illustrate microscopic aspects and will be accompanied by a literature review of opportunistic infections in the context of HIV infection. Results This article highlights aspects of fungal, parasitic, viral and selected bacterial infections of people living with HIV for whom the histopathological examination of tissue was an essential component of the clinical diagnosis. Histological features are noted on routine slides and accompanied by diagnostic features revealed with histochemical and immunohistochemical stains. Conclusion Medical practitioners working in areas of high HIV endemicity should be familiar with the variety of infectious diseases that are encountered and with the diagnostic importance of the histopathologist in clinical management.
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Affiliation(s)
- Reena Mohanlal
- Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,National Health Laboratory Services, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - Denasha L Reddy
- Division of Infectious Diseases, Department of Internal Medicine, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
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Flamm A, Alcocer VM, Kazlouskaya V, Kwon EJ, Elston D. Reply to "Comment on 'Histopathologic features distinguishing secondary syphilis from its mimickers'". J Am Acad Dermatol 2020; 83:e137. [PMID: 32278802 DOI: 10.1016/j.jaad.2020.03.106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alexandra Flamm
- Penn State Hershey Medical Center, Department of Pathology and Dermatology, Pennsylvania.
| | | | | | | | - Dirk Elston
- University of South Carolina, Department of Dermatology, Charleston
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Abstract
Infections of the central nervous system cause significant morbidity and mortality in immunocompetent and immunocompromised individuals. A wide variety of microorganisms can cause infections, including bacteria, mycobacteria, fungi, viruses, and parasites. Although less invasive testing is preferred, surgical biopsy may be necessary to collect diagnostic tissue. Histologic findings, including special stains and immunohistochemistry, can provide a morphologic diagnosis in many cases, which can be further classified by molecular testing. Correlation of molecular, culture, and other laboratory results with histologic findings is essential for an accurate diagnosis, and to minimize false positives from microbial contamination.
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Affiliation(s)
- Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Ro A, Mori S, Kageyama N, Chiba S, Mukai T. Ruptured Syphilitic Aneurysm: A Cause of Sudden Death in a Man with Human Immunodeficiency Coinfection. J Forensic Sci 2019; 64:1555-1558. [DOI: 10.1111/1556-4029.14046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Ayako Ro
- Department of Legal Medicine St. Marianna University School of Medicine Kanagawa 216‐8511 Japan
- Tokyo Medical Examiner's Office Otuska 4‐21‐18, Bunkyo‐ku Tokyo 112‐0012 Japan
| | - Shinjirou Mori
- Tokyo Medical Examiner's Office Otuska 4‐21‐18, Bunkyo‐ku Tokyo 112‐0012 Japan
| | - Norimasa Kageyama
- Department of Legal Medicine St. Marianna University School of Medicine Kanagawa 216‐8511 Japan
- Tokyo Medical Examiner's Office Otuska 4‐21‐18, Bunkyo‐ku Tokyo 112‐0012 Japan
| | - Shoetsu Chiba
- Department of Legal Medicine St. Marianna University School of Medicine Kanagawa 216‐8511 Japan
| | - Toshiji Mukai
- Department of Legal Medicine St. Marianna University School of Medicine Kanagawa 216‐8511 Japan
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Consider Syphilis in Case of Lymphopenia in HIV-Infected Men Who Have Sex with Men (MSM): A Single-center, Retrospective Study. Infect Dis Ther 2018; 7:485-494. [PMID: 30377976 PMCID: PMC6249181 DOI: 10.1007/s40121-018-0219-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction The way syphilis affects the immunologic and virologic parameters of a human immunodeficiency virus (HIV) infection remains controversial. The aim of this study was to investigate the impact of syphilis infection on lymphocyte and lymphocyte subset counts as well as viral load in HIV-infected patients. Methods All HIV-infected patients attending the outpatient clinic for infectious diseases of Hannover Medical University Hospital diagnosed with syphilis between 2009 and 2016 were retrospectively evaluated for changes in total lymphocyte, B cell, CD3+ T cell, CD4+ and CD8+ T cell counts as well as in HIV viral load. These parameters were assessed at three different time points, i.e., 3–6 months before, at diagnosis and 3–6 months after treatment of syphilis. Results Eighty-four HIV-infected patients, all with early syphilis, were identified. The vast majority were men who have sex with men (MSM), and 80% were receiving antiretroviral therapy (ART). Syphilis was associated with a significant reduction in the total lymphocyte count and counts of all studied lymphocyte subsets, including CD4+ T cells, whose percentage among lymphocytes did not change. No significant changes in HIV viral load were observed at any of the studied time points. Further, antibiotic treatment of syphilis restored lymphocyte counts back to pretreatment levels. Conclusion Syphilis induces a relative non-CD4+ T cell-specific lymphopenia in HIV-infected patients. Our data suggest that serologic testing for syphilis should be considered in HIV-infected MSM in case of an otherwise unexplained drop in total lymphocyte count. Electronic supplementary material The online version of this article (10.1007/s40121-018-0219-9) contains supplementary material, which is available to authorized users.
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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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Ruiz SJ, Procop GW. Cross-reactivity of Anti-Treponema Immunohistochemistry With Non-Treponema Spirochetes: A Simple Call for Caution. Arch Pathol Lab Med 2016; 140:1021-2. [DOI: 10.5858/arpa.2016-0004-le] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Sory J. Ruiz
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gary W. Procop
- Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio
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