Malignant Syphilis as an Initial Presentation of HIV Infection: A Case Report

Abstract

Introduction: Malignant syphilis (MS) is a rare and severe variant of secondary syphilis that is frequently associated with HIV infection. The clinical impact of HIV and syphilis co-infection is bidirectional, and the presence of MS is associated with acute HIV infection. Clinically, MS is characterized by nodular and ulcerative lesions affecting the trunk and extremities, which are covered with thick crusts. The treatment of choice for MS remains benzathine penicillin G.Herein, we report a case in which MS was the initial presentation of HIV infection.Case presentation: A 35-year-old male patient came with the chief complaint of extensive erythematous nodular rash for the past one month, with notable ulceration on some lesions with annular configuration along with fever and malaise. Based on the abovementioned clinical, laboratory, and histopathologic findings, the patient was diagnosed with MS and HIV. The diagnosis was established based on histopathological examination and syphilis serological testing.Discussion: Cutaneous disorders are a frequent presenting feature of HIV infection. The clinical manifestations of syphilis in immunosuppressed patients are often severe and/or atypical. The patient was then treated with weekly intramuscular administration of 2.4 million units of benzathine penicillin G for 3 weeks and achieved rapid and significant clinical improvement, with no Jarisch-Herxheimer reaction.Conclusion: Co-infection with syphilis and HIV alters the course of both diseases, and most HIV-infected patients with syphilis have typical disease manifestations associated with decreased CD4+ T-cell counts.

Malignant Syphilis: A Rare Case of Early Secondary Syphilis in an Immunocompetent Patient

“…These lesions mainly affect the trunk and extremities, but can also be present on the scalp, face, palms and soles [1-4, 6, 7] . Clinical suspicion of EMS can be supported by three criteria: clinical and histopathological characteristics; high titres of antibodies in VDRL or similar tests; and intense and severe JH and rapid resolution of lesions [1][2][3][4][5][6] .…”

“…Although recommendations for treatment of EMS are lacking in the literature and elsewhere [1][2][3][4][5][6][7] , the latest European guidelines recommend the use of one single dose of 2.4 M units of penicillin G benzathine [5] for the treatment of secondary syphilis.…”

“…First described by Bazin in 1859 and Dubuc in 1864 as a nodular variant of syphilis [1] , its presentation differs from the classic manifestations of secondary syphilis as it is more severe and has different lesion morphology. EMS, referred to in the literature as syphilis maligna praecox, rupioid syphilis or lues maligna, is characterized by pleomorphic multiple round-to-oval papules, papulopustules, or nodules with ulceration [1][2][3][4] . Cutaneous lesions are preceded approximately 4 weeks earlier by prodromal fever, headache, arthralgia, myalgia and weight changes [1,3] .…”

“…EMS, referred to in the literature as syphilis maligna praecox, rupioid syphilis or lues maligna, is characterized by pleomorphic multiple round-to-oval papules, papulopustules, or nodules with ulceration [1][2][3][4] . Cutaneous lesions are preceded approximately 4 weeks earlier by prodromal fever, headache, arthralgia, myalgia and weight changes [1,3] . The typical morphology and histopathology of the lesions, positive serological tests for syphilis, and resolution of the lesions after treatment with penicillin support the clinical diagnosis of EMS [2,3] .…”

“…Cutaneous lesions are preceded approximately 4 weeks earlier by prodromal fever, headache, arthralgia, myalgia and weight changes [1,3] . The typical morphology and histopathology of the lesions, positive serological tests for syphilis, and resolution of the lesions after treatment with penicillin support the clinical diagnosis of EMS [2,3] . The authors report a case of EMS in a young immunocompetent woman.…”