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Jimenez D, Rabe MS, Agarwal AN, Dalton SR, Anstead GM. An Exuberant Case of Ulceronodular-Rupioid (Malignant) Syphilis in an HIV Patient: A Proposal for New Diagnostic Criteria. Infect Dis Rep 2024; 16:499-518. [PMID: 38920894 PMCID: PMC11203149 DOI: 10.3390/idr16030038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 05/25/2024] [Accepted: 06/04/2024] [Indexed: 06/27/2024] Open
Abstract
We report the case of a 28-year-old male with uncontrolled human immunodeficiency virus (HIV) infection who presented with extensive ulcerated lesions with dark lamellated crusting on his face, torso, and limbs. The patient had a rapid plasma reagin (RPR) titer of 1:512, indicative of syphilis. A skin biopsy revealed granulomata surrounded by lymphocytes, histiocytes, and plasma cells, with spirochetes visible on immunohistochemical staining. The patient's rash resolved with hyperpigmented scarring after penicillin and doxycycline treatment. This severe form of secondary syphilis has been termed malignant syphilis, lues maligna, ulceronodular syphilis, or rupioid syphilis. We propose a single descriptive name for this entity, ulceronodular-rupioid syphilis. In 1969, Fisher proposed criteria for malignant syphilis based on lesion appearance, histopathologic findings, high RPR values, and rapid response to treatment. We found that the Fisher criteria were imprecise with respect to specific histopathologic findings, the quantitation of RPR values, and what constitutes rapid response to treatment. Thus, we examined an additional 74 cases from the literature and propose new diagnostic criteria based on rash appearance, histopathologic characteristics, non-treponemal and treponemal test positivity, and response to therapy. We also found that uncontrolled viremia, and not a low CD4 count, is a major risk factor for ulceronodular-rupioid syphilis in HIV patients.
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Affiliation(s)
- Dennys Jimenez
- Department of Medicine, Division of Infectious Diseases, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA;
| | - Marian Santillan Rabe
- Family-Focused AIDS Clinical Treatment Services Clinic, University Health System, 903 W. Martin St., San Antonio, TX 78207, USA;
| | - Apeksha N. Agarwal
- Department of Pathology, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA;
| | - Scott R. Dalton
- Sagis Diagnostics, PLLC, 4131 Directors Row, Houston, TX 77092, USA;
| | - Gregory M. Anstead
- Department of Medicine, Division of Infectious Diseases, University of Texas Health San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA;
- Family-Focused AIDS Clinical Treatment Services Clinic, University Health System, 903 W. Martin St., San Antonio, TX 78207, USA;
- Medical Service, Division of Infectious Diseases, South Texas Veterans Healthcare System, 7400 Merton Minter Blvd., San Antonio, TX 78229, USA
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Maharani RH, Nugraha T, Sutedja E, Ruchiatan K, Usman HA, Achdiat PA. Generalized Asymptomatic Nodulo-Ulcerative Lesions Without Systemic Symptoms in a Secondary Syphilis Patient Co-Infected with HIV. Clin Cosmet Investig Dermatol 2023; 16:3645-3650. [PMID: 38144158 PMCID: PMC10749176 DOI: 10.2147/ccid.s445155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/17/2023] [Indexed: 12/26/2023]
Abstract
Syphilis is a sexually-transmitted disease with various clinical stages. Secondary syphilis manifestations may mimic other skin lesions. Patient co-infected with Human Immunodeficiency Virus (HIV), with CD4 cell counts of 200-499 cells/mm3, often manifests an atypical cutaneous lesion, which may also occur as nodular or ulcerative lesions. Generalized nodulo-ulcerative lesions without systemic symptoms in secondary syphilis patients with HIV co-infection are rarely reported. A 22-year-old man presented with generalized asymptomatic multiple erythematous papules and plaques with scales, as well as nodular and nodulo-ulcerative lesions on the trunk, both arms, and both legs. His lesions spread progressively without the presence of any prodromal symptoms or adenopathy. He was previously diagnosed with HIV and is currently on antiretroviral medications, with a CD4 cell count of 388 cells/μL. His venereal disease research laboratories (VDRL) result was reactive (titer of 1:256). His Treponema pallidum hemagglutination assay (TPHA) result was also reactive (titer of 1:10,240). A skin biopsy was performed from the nodulo-ulcerative lesion on his back. Hematoxylin-eosin staining revealed a hyperplastic epidermis, a massive influx of plasma cells, and lymphocyte infiltration into the deep dermis, especially in the peri-adnexal, peri-vascular, and peri-muscular regions. The patient was diagnosed with secondary syphilis with HIV co-infection. He had no previous history of drug allergy. A single dose of 2.4 million units of benzathine penicillin G was administered. Almost all the lesions became hyperpigmented macules after two weeks and resolved completely after one month. His VDRL titer declined to 1:32 after three months. The various atypical lesions of secondary syphilis may lead to misdiagnosis and delayed treatment. The presence of multiple asymptomatic nodulo-ulcerative lesion without prodromal symptoms may indicate the presence of secondary syphilis, notably in patients co-infected with HIV. Therefore, knowledge of atypical cutaneous manifestations of secondary syphilis is warranted in order to treat patients accordingly.
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Affiliation(s)
- Retno Hesty Maharani
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Tomi Nugraha
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Endang Sutedja
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Kartika Ruchiatan
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Hermin Aminah Usman
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
| | - Pati Aji Achdiat
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin Hospital, Bandung, Indonesia
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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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Diagnosis and Management of Syphilis in Patients With HIV Co-infection. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2020. [DOI: 10.1007/s40506-020-00225-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Fernandez-Nieto D, Ortega-Quijano D, Jimenez-Cauhe J, Fernandez-Gonzalez P, Moreno-Moreno E, Bea-Ardebol S. Secondary syphilis mimicking tuberculoid leprosy in an HIV-positive individual: a case report. Int J STD AIDS 2019; 30:1235-1238. [PMID: 31558132 DOI: 10.1177/0956462419869136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Secondary syphilis is a polymorphic condition resulting from the hematogenous and lymphatic dissemination of Treponema pallidum. Human immunodeficiency virus-positive patients are in greater risk of atypical and severe forms of the disease. The most common manifestation is a generalized papulosquamous eruption with variable mucosal involvement. However, annular plaques, split commissural papules, crusted necrotic or ulcerated lesions are also frequent. Granulomatous lesions, both clinically and histologically, are less common and present a diagnostic challenge. We describe a case of secondary syphilis presenting as a granulomatous rash with both clinical and histological features of tuberculoid leprosy. Complementary tests and clinical suspicion are essential to ensure a correct diagnosis and avoid subsequent complications.
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Affiliation(s)
- D Fernandez-Nieto
- Department of Dermatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - D Ortega-Quijano
- Department of Dermatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Jimenez-Cauhe
- Department of Dermatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - E Moreno-Moreno
- Department of Pathology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - S Bea-Ardebol
- Department of Dermatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
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