The great impostor: Lues maligna in an HIV-infected male

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.

Sífilis Maligna Precoce em Paciente Imunodeprimido

“…17 As características histológicas de SM podem incluir achados inespecíficos, como o predomínio de infiltrado inflamatório de linfócitos e plasmócitos na derme papilar e média, sobretudo perivascular, acompanhado de edema endotelial e necrose fibrinóide dos vasos superficiais e profundos, podendo ser encontrada infiltração granulomatosa e células gigantes, eventualmente espiroquetas. 13,18 A dificuldade em encontrar espiroquetas ocorre principalmente com a coloração de Steiner, sendo mais fácil identificá-las com a coloração Warthin-Starry. 19 A imuno-histoquímica é superior na detecção de espiroquetas em comparação com as colorações com prata, porém é de reduzido acesso.…”

Multiple rapidly growing necrotic eruptions on the face

“…To our knowledge, < 50 cases of HIV-related malignant syphilis have been reported in the literature. 6 It is not rare that malignant syphilis presents as the first sign of a hidden HIV infection, thus investigations for immunodeficiency-inducing factors, particularly HIV infection, is essential.…”

Ulceronecrotic Lesions in a Man with Familial Mediterranean Fever: A Quiz

“…Immunodeficiency caused by HIV may favour the predominance of the agent's virulence in the agent-host-contest (1). Malnutrition, alcohol abuse, diabetes, intravenous drug use and concomitant debilitating disorders are also reported as predisposing factors for LM (1,(3)(4)(5). Nevertheless, few cases are described in immunocompetent patients (1,3,4).…”

“…LM, as secondary syphilis in general, often acts as "great mimicker" and should be considered as a differential diagnosis in multiple clinical settings, both in immunosuppressed and immunocompetent populations (8). LM eruptions have been reported to mimic malignant (cutaneous T-cell lymphoma), infectious (fungal, bacterial and mycobacterial infections) and inflammatory (pityriasis lichenoides et varioliformis acuta, necrotizing vasculitis, pustular psoriasis, erythema exudativum, sarcoidosis) dermatoses (1,5).…”