Acta Dermato-Venereologica 99-12CompleteContent | Page 39

SHORT COMMUNICATION 1197 Delayed Onset and Protracted Course of Psoriasis-like Secondary Syphilitic Lesions in a HIV-sero­ positive Man Who has Sex with Men: A Case Report Rui-Rui PENG 1 , Shuxian SHANG 2 , Jia CHEN 3 , Mei SHI 1 and Fu-Quan LONG 1 * STD Institute and 3 Department of Dermatopathology, Shanghai Dermatology Hospital, Tongji University School of Medicine, Shanghai 210043, and 2 Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, Nanjing, China. *E-mails: [email protected] or [email protected] 1 Accepted Aug 22, 2019; E-published Aug 22, 2019 Syphilis is a chronic sexually transmitted infection caused by Treponema pallidum. The protean cutaneous manifestations of secondary syphilis span a wide spec- trum and have earned the name of “the great imitator” (1, 2). Secondary syphilitic lesions usually occur within 3 months after initial exposure to T. pallidum and last for 4 to 12 weeks (3). However, co-infection with HIV may alter the clinical presentation and course (4). Here, we report a long-term misdiagnosed HIV-seropositive homosexual man presenting with psoriasis-like secon- dary syphilitic lesions, which appeared approximately 3 years after initial infection and had a protracted course over one year. Such notable deviations from the normal expectations have never been reported. CASE REPORT A 30-year-old man who complained of skin rashes and hair loss for more than one year was referred to our STD clinic in August 2017. He denied any sexual behaviour except for two episodes of unprotected anal sex with men in July 2012 and March 2013. His serological tests for HIV and syphilis were all negative before his last sexual encounter. He was diagnosed with HIV infection in July 2013; at that time his CD4 + T-cell count was 46 cells/ul. He concealed his HIV status from his family members and doctors. He started highly active antiretroviral therapy in September 2016, but he ceased treatment voluntarily after 3 months because of profoundly pessimistic thoughts. The patient had experienced gradual hair loss and recurrent scalp dermatitis since July 2016. He had been diagnosed with psoriasis with concomitant alopecia for more than one year and was tested for syphilis and HIV in the dermatology clinics. He received intermittent therapy with a topical steroid ointment without improvement. The lesions progres- sively expanded to involve his neck, shoulders, wrists, feet and genitals. Physical examination revealed patchy alopecia and multiple varisized infiltrated flat red psoriasis-like pla- ques involving the scalp, neck, face, shoulders, feet and genitals (Fig. 1). He had axilla, neck, submaxilla and groin lymphadenopathy. The T. pallidum particle assay was positive with a toluidine red unheated serum test titre of 1:64. His HIV viral load was 151 copies/ml, and his CD4 + T-cell count was 15 cells/µl. Cerebrospinal fluid tests indicated slightly elevated leukocyte (15 cells/μl) and protein levels (60 mg/dl), but the Venereal Disease Research Laboratory test was negative. A skin biopsy taken from a left wrist lesion revealed that the epider- mis was irregularly proliferated, dermal papillae were oedematous, and perivascular plasma cells had infiltrated the superficial dermis (Fig. 2a). Immunohistochemical analysis using a polyclonal antibody against T. pallidum showed numerous spirochetes (Fig. 2b). The diagnosis of secondary syphilis and HIV infection was confirmed. The patient received 4 million units of benzylpenicillin intravenously every 4 h for 14 days. His skin lesions and Fig. 1. a) Patchy alopecia and red psoriasis-like plaques on the patient’s scalp and neck. b) Red plaques on the patient’s neck and jaw and dry erythema on his lips. Several varisized red and flat-topped, hypertrophic, verrucous and psoriasis-like plaques on the patient’s wrists (c) and genital area (d). This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica. doi: 10.2340/00015555-3302 Acta Derm Venereol 2019; 99: 1197–1198