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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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Karanfilian KM, Almohssen AA, Kapila R, Schwartz RA. Malignant syphilis: a new and revised definition. Int J Dermatol 2023; 62:369-375. [PMID: 36250867 DOI: 10.1111/ijd.16444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 08/07/2022] [Accepted: 09/22/2022] [Indexed: 12/01/2022]
Abstract
Malignant syphilis is a rare, severe variant of secondary syphilis that primarily affects immunocompromised patients. Historically, the clinical presentation included a prodrome of constitutional symptoms followed by the development of characteristic skin lesions. The definition of malignant syphilis has not been updated since it was first described as only a cutaneous manifestation. In recent years, syphilis has reemerged as a major public health issue, particularly in men who have sex with men (MSM) and patients with HIV. With increasing rates of syphilis in the HIV-positive population, the systemic manifestations of malignant syphilis have become more apparent. We propose a revised definition and elucidate why the term malignant syphilis should be expanded to include systemic manifestations, stressing musculoskeletal, central nervous system, ocular, ear, cardiovascular, rectal, liver, lung, and renal involvement. This updated definition is dramatically expanded to reflect its systemic manifestations. Recognition of these manifestations may prevent devastating long-term effects.
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Affiliation(s)
| | | | - Rajendra Kapila
- Infectious Disease, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Robert A Schwartz
- Dermatology and Pathology, Rutgers New Jersey Medical School, Newark, NJ, USA
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Dimnik J, Benko M, Hosta V, Murnik Rauh A, Pagon A, Špik VC, Battelino S, Vozel D. Malignant Syphilis in a Female Patient: A Case Report and Mini-Review. Trop Med Infect Dis 2022; 7:tropicalmed7030047. [PMID: 35324594 PMCID: PMC8950934 DOI: 10.3390/tropicalmed7030047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/03/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
Malignant syphilis (MS) is a rare form of secondary syphilis with grotesque skin lesions, systemic manifestation and life-threatening complications. This article presents a case of MS in an immunocompetent 41-year-old female, who initially manifested with a generalized nonpruritic erythematous rash and systemic symptoms. She was mistreated for generalized impetigo and hepatitis attributed to chronic alcoholism. After partial recovery and a 3-month latent period, she developed infiltrated plaques with crusts on the trunk, head and neck; pharyngitis and laryngeal lesions; generalized lymphadenopathy and nonspecific systemic symptoms. Serologic tests confirmed syphilis, and cerebrospinal fluid analyses indicated the presence of anti-treponemal antibodies. Urine drug screening was positive for cannabinoids. The polymerase chain reaction from skin biopsy samples identified T. pallidum, confirmed with Warthin-Starry staining. Immunohistochemical analysis was uncharacteristic. Tertiary syphilis, neurosyphilis, ocular syphilis and otosyphilis were excluded. However, the patient was treated for neurosyphilis with benzylpenicillin (18 million IU intravenously daily, 14 days) and corticosteroids. No Jarisch-Herxheimer reaction occurred. Ten months after treatment, residual scars were visible, and 1 year later, she attempted suicide. Since MS can resemble other diseases, it should be suspected in a mentally ill patient with chronic drug abuse, systemic nonspecific manifestations and dermatological abnormalities, including the head and neck region.
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Affiliation(s)
- Julija Dimnik
- Department of Dermatovenereology, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia; (J.D.); (M.B.); (V.H.); (A.M.R.); (A.P.)
| | - Maja Benko
- Department of Dermatovenereology, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia; (J.D.); (M.B.); (V.H.); (A.M.R.); (A.P.)
| | - Violeta Hosta
- Department of Dermatovenereology, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia; (J.D.); (M.B.); (V.H.); (A.M.R.); (A.P.)
| | - Andreja Murnik Rauh
- Department of Dermatovenereology, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia; (J.D.); (M.B.); (V.H.); (A.M.R.); (A.P.)
| | - Andreja Pagon
- Department of Dermatovenereology, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia; (J.D.); (M.B.); (V.H.); (A.M.R.); (A.P.)
| | - Vesna Cvitković Špik
- Faculty of Medicine, Institute of Microbiology and Immunology, University of Ljubljana, SI-1000 Ljubljana, Slovenia;
| | - Saba Battelino
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia
| | - Domen Vozel
- Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, SI-1000 Ljubljana, Slovenia;
- Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia
- Correspondence:
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Kapila R, Schwartz RA. Neurosyphilis and the Jarisch-Herxheimer reaction: A therapy concern with HIV disease. Dermatol Ther 2021; 34:e14839. [PMID: 33527658 DOI: 10.1111/dth.14839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/24/2021] [Accepted: 01/27/2021] [Indexed: 11/29/2022]
Abstract
Jarisch-Herxheimer reaction (JHR) should be anticipated in treating neurosyphilis with coexistent human immunodeficiency virus (HIV) encephalitis. In that context we have devised a staging classification for JHR. In addition, an illustrative case is provided to emphasize the need to consider the diagnosis of neurosyphilis in HIV patients, and if delineated, to be prepared for a severe JHR.
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Affiliation(s)
- Rajendra Kapila
- Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Robert A Schwartz
- Medicine, Dermatology, Pathology, and Pediatric, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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