Malignant syphilis in HIV-infected patients

A Peculiar Presentation of Syphilis as a Mysterious Rash: A Dermatological Dilemma

A renowned poet in the ancient city of Verona by the name of Girolamo Fracastoro coined the term syphilis in 1530. The stigma and shame that embodied this affliction has been time immemorial and disabling for patients. The hypothesis of the spread from the warm tropics of west and central Africa to the Iberian Peninsula accompanied by the slave trade has been a tale for centuries. Malignant syphilis is a rare skin manifestation of Treponema pallidum infection and a variant of secondary syphilis. The rash is frequently associated with HIV-infected patients, often with low cluster differentiation 4 (CD4) cell count. The authors reported a unique case involving a 46-year-old woman who presented with a one-week history of skin eruptions at various stages. Subsequent laboratory tests revealed a strong positive result for Treponema pallidum and a positive Rapid Plasma Reagin (RPR) test with a titer of 1:16. She received doxycycline because she had a history of penicillin anaphylaxis in the past. She did well, with a remarkable improvement in symptoms - a positive outcome for this catastrophic stigmatizing, rare diagnosis.

Human immunodeficiency virus-positive secondary syphilis mimicking cutaneous T-cell lymphoma

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.

Malignant syphilis in an AIDS patient

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.

Lues Maligna in a Chronic Alcoholic Patient

Lues maligna, which is characterized by noduloulcerative lesions, is a rare form of secondary syphilis. It is mainly seen in either HIV-infected or malnourished patients suffering from a depression in immunity. We presented a chronic alcoholic, HIV negative male patient with noduloulcerative lesions diagnosed as lues maligna based on his skin eruptions, results of serologic tests, and, histopathologic findings. We believe that chronic alcoholism could be the cause of immunosuppression in our case and wanted to emphasize the possibility of an association between lues maligna and chronic alcoholism.

Malignant lues in an immunocompetent patient

Malignant lues is a rare form of secondary syphilis mostly associated with HIV infection. It is an uncommon presentation of syphilis even rarer in immunocompetent patients. We present the case of a 57-year-old homosexual man referred to our department due to a 4-month history of a disseminated, slightly painful, nodular-ulcerative cutaneous eruption associated with low-grade fever, malaise and aesthenia. Regarding the clinical features and serological and histopathological findings, the diagnosis of syphilis maligna was assumed. Serology for HIV was repeatedly negative. This case is interesting, not only because a very uncommon form of secondary syphilis was identified but also for being diagnosed in an immunocompetent patient. Lack of awareness of this type of presentation delays the diagnosis and treatment, leading to an increase in morbidity and spread of infection.

Malignant syphilis as the first manifestation of HIV infection

Malignant syphilis is a rare and severe variant of secondary syphilis. It is clinically characterized by large papular, nodular and ulcerative lesions affecting the trunk and the extremities and covered with thick crust. We present a case of 52-year-old homosexual male who developed malignant syphilis and this was the first clinical manifestation of HIV infection. The patient was treated successfully with intravenous aqueous crystalline penicillin G. Physicians should recognize malignant syphilis and consider it in all HIV-infected individuals with ulceronodular skin lesions.

Pathologically confirmed malignant syphilis in an HIV-infected patient

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.

A case of lues maligna in a patient with acquired immunodeficiency syndrome (AIDS)

We report a case of lues maligna (ulceronodular cutaneous syphilis) mimicking mycosis fungoides in an individual with AIDS and review the literature of this variant of syphilis in human immunodeficiency virus (HIV)-infected individuals. A comparison of the histological similarities and differences between lues maligna, late cutaneous syphilis and mycosis fungoides is also discussed.

Lues maligna in an HIV-infected patient

We report such a case of malignant syphilis in a 42-year-old HIV-infected man, co-infected with hepatitis B virus, who presented neurolues and the classical skin lesions of lues maligna. The serum VDRL titer, which was 1:64 at presentation, increased to 1:2,048 three months after successful therapy with penicillin, decreasing 15 months later to 1:8.

Secondary syphilitic lesions

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

The immune compromised host in the twenty-first century: management of mucocutaneous infections

Infectious diseases encountered in dermatology have changed tremendously during the past few decades with the emergence of the immunocompromised host. This change is a result of the human immunodeficiency virus epidemic, use of immunomodulating drugs, bone marrow transplantation, increasing prevalence of diabetes mellitus, and an aging population. New pathogens have been discovered and new disorders have occurred. In the compromised host, infection can be more aggressive and widespread locally, be caused by opportunistic pathogens, and be disseminated hematogenously from or to the skin. The prevalence of nonmelanoma skin cancer has increased, and squamous cell carcinomas can be more aggressive with more rapid local growth as well as frequency of metastasis.

Malignant syphilis: a review

Syphilis is a disorder that may mimic many other diseases. Its incidence has risen and fallen over the centuries. A particularly malignant and virulent form, lues maligna, has recently been more frequently observed in the HIV-infected population. Raising the awareness of the occurrence of and the clinical and laboratory criteria of syphilis in general and lues maligna in particular in the HIV-infected population is becoming more urgent. Early treatment can result in a good outcome and stem the spread of the disease; as with other forms of syphilis, penicillin is the drug of choice.

Malignant syphilis (lues maligna) and concurrent infection with HIV

BACKGROUND

During the past 2 1/2 years we observed six patients who had a reactive serology for syphilis, of which four developed widespread noduloulcerative and two vesiculonecrotic lesions. The purpose was to report the occurrence of lues maligna, a rare form of secondary syphilis, in five patients infected with the human immunodeficiency virus (HIV) and in one patient with risk factors for infection.

METHODS

Tzanck preparations, viral cultures, and skin biopsies were performed to evaluate the etiology of the lesions.

RESULTS

Syphilis serology titers ranged from 1:32 to 1:128 and in one instance was as low as 1:8. Such titers can also be found in patients with the latent form of syphilis. Therefore, confirmation of the clinical diagnosis of lues maligna was dependent on skin biopsies that were compatible with secondary syphilis and negative viral studies that excluded varicella, disseminated varicella-zoster or herpes simplex. Lues maligna takes an aggressive course in HIV-infected patients since four of the patients required hospitalization and the two patients who refused to complete treatment, subsequently developed more severe skin and constitutional symptoms.

CONCLUSIONS

HIV-infected patients are at risk for developing lues maligna. Despite its malignant presentation, lues maligna lesions respond rapidly to treatment with penicillin. Secondary syphilis should be added to the list of diseases known to be more aggressive in HIV-infected patients.

Clinical expression of secondary syphilis in a patient with HIV infection

There are increasing reports of unusual clinical features and atypical courses of syphilis in patients with acquired immunodeficiency syndrome. Recently, we had the opportunity to study an HIV-positive female patient with strong manifestations of secondary syphilis. The case is discussed together with the implications of secondary syphilis in her concomitant ocular affliction. Moreover, we comment on the clinico-therapeutic controversies brought about by the association of infection with Treponema pallidum and HIV.

Early oral presentation of lues maligna in a patient with HIV infection. A case report

We present a case of a patient infected with the human immunodeficiency virus who developed syphilis manifested by atypical early oral and skin ulcerations. The profound immune defects associated with human immunodeficiency virus may lead to an altered clinical presentation and a more aggressive course in patients infected with Treponema pallidum. The unusual clinical manifestations observed in this case emphasize the importance of considering secondary syphilis in the differential diagnosis of any inflammatory mucosal and skin disorder in patients with the human immunodeficiency virus.

Ocular syphilis

There has been a steady increase in the number of cases of syphilis in the United States since the middle 1980s, with a dramatic rise in incidence among heterosexual men and women and of congenital syphilis. There also have been changes in geographic distribution of cases and an association with cocaine use. The ophthalmologic manifestations of syphilis are broad. There is anecdotal evidence that the natural history of syphilitic infection is altered by coinfection with human immunodeficiency virus. The potential of coinfection with HIV makes the clinical evaluation, treatment, and assessment of therapeutic outcome of syphilitic infection more confounding and controversial. This article provides a review of the changing demographics and ophthalmic manifestations of syphilis, the current status of laboratory testing techniques, and management approaches to various types of ocular syphilis.