P1246990957LvnHC

1
An old enemy strikes back Malignant syphilis
German Luy, MD, Cathy Logan, MD, Gustavo
Heudebert, MD The University of Alabama at
Birmingham - Birmingham, Alabama

Diagnostic Studies
Background

• Syphilis can have atypical presentations in
  HIV patients
• There is a current outbreak of syphilis in
  Jefferson
• county, AL

• Positive RPR ( 164) and FTA abs
• Skin Bx Mixed dermal inflammatory infiltrate
  with presence of spirochetes
• on an immunoperoxidase stain .Special stains
  for fungi (PAS) and
• mycobacteria (AFB) were negative

Learning Objectives

• To recognize the clinical presentation of
  malignant
• syphilis

Malignant Syphilis
History and PE

• Malignant syphilis is an infrequent form of
  secondary syphilis
• characterized by a prodrome of fever,
  myalgias and headache followed
• by a papulo-pustular eruption that rapidly
  transforms into necrotic and
• sharply marginated ulcers with hemorrhagic
  brown crusts. (1)
• Malignant syphilis in 60 times more frequent in
  HIV patients compared
• to the general population . (2)
• It's also associated with malnutrition , IVDU
  and alcoholism.
• Most of the reported cases associated with HIV
  had a CD4 count 200
• cells and an ocular compromise occurred in
  1/3 of the patients. (3)
• The differential diagnosis in HIV patients
  with necrotic and pustular

• HPI
• A 35 yo caucasian female presented with a 2
  week history of a diffuse pruritic and painful
  rash , associated with malaise,myalgias and
  fevers up to 102.
• PMHx
• HIV since 1996, No HAART Tx
• No prior OIs . CD4 11 in 2005
• No current medications
• Cocaine abuse . Reportedly monogamous .
• PE T 101.8 , HR90 x , 110/70
• Thin white female in NAD
• The skin exam showed a diffuse symmetric
• polymorphic rash in her face ,trunk and
• extremities including palms and soles ,
  characterized
• by discrete erythematous
  papular-pustular lesions,
• some with crusted necrotic centers,
  ranging in size
• from 5 to 25 mm
• Her oral exam showed three small ulcers in
  the hard
• palate

References

• Kumar B, Muralidhar S .Malignant syphilis A
  Review. AIDS Patient Care and STDs 1998.
  Volume 12 . 921-25
• Schofer H, Imhof M, Thoma-Greber E et al. Active
  syphilis in HIV infection a multicentre
  retrospective survey. The German AIDS Study Group
  (GASG). Genitourin Med 1996 72 176-81.
• Romero-Jimenez M.J , Suarez-Lozano I,
  Fajardo-Pico J.M et al. Malignant syphilis in
  patient with Human Immunodeficiency Virus (HIV)
  Case report and literature review. AN. MED.
  INTERNA (Madrid) 2003 . Vol. 20, N.º 7 373-76
• Don Pc, Rubinstein R, Christie R. Malignant
  syphillis an concurrent infection with HIV. Int J
  Dermatol 199534 403-407
• Wappner D,Carbia S, Gioseffi L et al. Diagnosis
  Malignant syphilis. Clin Infect Dis
  1997251343,1447
• Tosca A, Stravopoulos PG, Hatziolou E et al.
  Malignant syphilis is HIV infected patients. Int
  J Dermatol 1990,29 575-578

References

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Take Home Point