Secondary syphilis presenting with atypical skin lesions: a case report
Dr Nina Yancheva at Department of Infectious Diseases, Parasitology, and Tropical Medicine, Medical University – Sofia, Bulgaria and colleagues have reported a rare case of Secondary syphilis presenting with atypical skin lesions. The case has appeared in the Journal of Medical Case Reports.
Untreated syphilis may lead to severe complications. This infection has recently re-emerged in developed countries with a high number of cases coinfected with human immunodeficiency virus. In these patients, the skin lesions of secondary syphilis can be very atypical.
A 38-year-old Bulgarian homosexual man who was HIV-seropositive who reportedly had several sexual partners came to the hospital. He neither smoked tobacco nor drunk alcohol; he actively practised Taekwondo. He presented with fever, chills, malaise, and multiple cutaneous lesions with a purulent secretion that covered his face, scalp, and body. The skin lesions had appeared several months prior to a diagnosis. He explained that the initial lesions had looked like "pimples," but subsequently had become "bubbles" filled with pus. Initial clinical diagnoses had included varicella pustulosa and staphylococcal dermatitis. He had been treated in out-patient settings with orally administered acyclovir 5 × 800 mg for 7 days and amoxicillin-clavulanic acid 3 × 1.0 g for 10 days. After an outbreak of fever and rash for approximately a week, his complaints had reappeared with more pronounced intensity and had continued for 2 months until a diagnosis was established. Following an out-patient visit to another dermatologist, he had been referred for syphilis and HIV testing. Specifically, the rapid plasma reagin (RPR) test and the Treponema pallidum particle agglutination assay (TPPA) had turned positive. It was established that 2 years earlier in prophylactic studies, he had been diagnosed as having an HIV infection and his result had been confirmed by the National Reference Laboratory for HIV in Sofia, Bulgaria. He claimed that he had not been aware of the diagnosis and had not been treated for it. He was therefore hospitalized at the Department for AIDS. A physical examination revealed extensive necrotic lesions on his face and head with abundant purulent secretion in the absence of lesions on his palmar and plantar surfaces, as well as the described papular lesions on his torso and, more scarcely, on his extremities. The most significant necrotic lesions occurred on his lips, and those produced the most purulent secretion. He was febrile and had lymphadenopathy and oropharyngeal candidiasis.
The physical examination on admission found fever of up to 39 ºC and generalized lymphadenomegaly. His breathing was clear, without any wheezing. His heart rate was 123 beats per minute and his blood pressure was 130/100 mmHg. No hepatosplenomegaly was detected. A neurological examination established no pathological findings.
The laboratory work showed evidence of anaemia with haemoglobin (Hb) of 117 g/l and high leukocytosis with white blood cells (WBC) of 18.8 G/l and granulocytosis with granulocytes (Gran) of 91%. The biochemical tests were also normal: alanine aminotransferase (ALAT), 39 U/l; aspartate aminotransferase (ASAT), 32 U/l; glucose, 4.05 mmol/l; creatinine, 74.73 μmol/l; and total cholesterol, 2.8 mmol/l. Urine analysis revealed the following: pH, 6.0; protein, negative; glucose, negative; and bilirubin, negative.
Immune status tests showed a CD4 cell count of 208 cells/μl, a CD8 count of 845 cells/μl, and a CD4/CD8 ratio of 0.20. The viral load for HIV was 745,000 copies/μl.
Microbiological examinations were performed on throat secretions, nasal secretions, sputum, uroculture, and hemoculture. The samples were collected and transported in sterile conditions. Seeding of media for aerobic and anaerobic microorganisms was done. The only isolated microorganism was Candida albicans in non-significant amounts in sputum.
An X-ray of his lungs and heart revealed no pathological findings.
A skin biopsy was performed, and a histological examination showed non-specific inflammatory changes: a moderate mixed inflammatory infiltrate located perivascularly throughout the dermis, which was composed of lymphocytes, plasmacytes, and polymorphonuclear cells.
Due to a lack of penicillin, our patient was given a 21-day course of ceftriaxone 2 × 2.0 g administered intravenously in combination with amikacin 2 × 500 mg administered intravenously and metronidazole 3 × 500 mg administered intravenously, parallel to the administration of an antimycotic agent, fluconazole 200 mg administered intravenously, for the oropharyngeal candidiasis. The idea was to cover all possible superposed infections with Gram-negative and anaerobic bacteria, too. Our patient also began antiretroviral therapy with the following combination: emtricitabine/tenofovir disoproxil fumarate 0.445 + dolutegravir 0.050. A month after the onset of treatment, he was discharged with an almost complete reversal of the skin lesions. His upper lip was seen to be retracted after the reversal of the necrotic lesions (Fig. 4). Three months later, an RPR test was negative, the CD4+ T count was elevated (to 522 cells/μl), and so was the CD4/CD8 ratio (0.58), while the viral load became undetectable (< 40 copies/μl).
Unfortunately, as of May 2019, our patient has not visited our Department and has not been followed up since then.
Journal of Medical Case Reports
For more details click on the link: https://doi.org/10.1186/s13256-019-2291-5
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