Conflicts of interest: None.
Late secondary syphilis with nodular lesions mimicking Kaposi sarcoma in a patient with human immunodeficiency virus
Article first published online: 4 APR 2013
© 2013 The International Society of Dermatology
International Journal of Dermatology
Volume 53, Issue 1, pages e71–e73, January 2014
How to Cite
Yayli, S., della Torre, R., Hegyi, I., Schneiter, T., Fux, C., Beltraminelli, H. and Borradori, L. (2014), Late secondary syphilis with nodular lesions mimicking Kaposi sarcoma in a patient with human immunodeficiency virus. International Journal of Dermatology, 53: e71–e73. doi: 10.1111/j.1365-4632.2012.05598.x
- Issue published online: 18 DEC 2013
- Article first published online: 4 APR 2013
Syphilis, the “great imitator,” is even more difficult to diagnose in patients with human immunodeficiency virus (HIV), in whom more aggressive or atypical clinical presentations have been reported.1 We herein describe a case of syphilis in a patient with HIV presenting with generalized skin lesions closely mimicking Kaposi sarcoma. Although nodular syphilis is usually a feature of cutaneous tertiary syphilis, patients with HIV may present with such lesions already in the early phase of syphilis infection.2
A 72-year-old female patient with HIV was evaluated for a 3-week history of indolent skin lesions on her face, shoulder, arms, and legs. Mucosal and genital lesions were denied. The patient had been diagnosed with HIV 16 years earlier and currently was in CDC stage A2. She was in good general condition and, in particular, did not complain about fever, weight loss, or night sweats.
On examination, she had multiple dark red and violaceous nodular lesions on the left eyebrow, in the right axilla, on the shoulders as well as on the left leg and arm. The lesions were non-tender, infiltrated, or even indurated (Fig. 1). There were no palpable lymph nodes except for one painless, mobile, soft cervical node of 1 cm in diameter.
Light microscopy studies of a biopsy specimen obtained from the left arm showed acanthotic epidermis and patchy parakeratosis with a superficial and deep inflammatory infiltrate composed of lymphocytes, histiocytes, and plasma cells. Furthermore, in the papillary and superficial reticular dermis, a granulomatous infiltrate component was also observed (Fig. 2). The periodic acid-Schiff and Ziehl–Neelsen stains were negative for fungi and mycobacterium species, respectively. Despite no recent history of recent mucogenital lesions, testing for syphilis revealed a serum Venereal Disease Research Laboratory (VDRL) positive at 1 : 128 dilution, Treponema pallidum hemagglutination positive at 1 : >327.680. The lymphocyte stimulation test for mycobacterium tuberculosis complex was negative. The CD4 cell count was 307 cells/μl (8%), the HIV-RNA 3.905 copies/ml. Chest radiography was normal, without evidence for a calcification of the ascending aorta. Echocardiography showed no signs of aortic insufficiency. Neurological examination was normal, without vibratory sensation impairment, Argyll–Robertson pupils, ataxia, incontinence, cranial nerve disorders, hyperactive reflexes, and speech disturbance. As the patient did not want to undergo any further tests to exclude neurological involvement, we proposed a 14-day course of intravenous penicillin G infusion, 24 million IU daily, but she refused. The patient was ultimately given short daily infusions of ceftriaxone, 2 g daily, for two weeks with good tolerance, based on previous recommendations.3 Within two months, the lesions almost completely cleared (Fig. 3). At this time, VDRL was still positive at 1 : 64 dilution. The patient was subsequently lost to follow-up.
The change in clinical manifestations of syphilis has been observed in the last couple of decades. HIV coinfection appears to represent a major cause for this phenomenon.4 While syphilis increases the risk of HIV transmission, some clinical differences in syphilis presentation may occur in patients with HIV. In the latter, increased number of primary lesions, more aggressive primary forms, increased rates of concomitant primary and secondary phases of syphilis, rapid progression to tertiary syphilis, including neurosyphilis, as well as occurrence of malignant ulcerative forms of syphilis have been described.1 Atypical presentations, which may potentially mimic even leprosy or malignancies such as cutaneous T-cell lymphomas, may result in misdiagnosis.5,6
In our experience, our case was unusual and striking, based on the presence of multiple disseminated, infiltrated dark red, violaceous plaques and nodules, which appeared clinically undistinguishable from HIV-associated Kaposi sarcoma. Only histopathological evaluation and serologic testing allowed us to revise the diagnosis. Although nodular lesions usually are a manifestation of tertiary syphilis, secondary syphilis may also rarely appear as cutaneous nodules.7–9 Cutaneous or mucosal nodular lesions have also been previously anecdotally described in HIV-coinfected patients.2,10 Baniandrés Rodríguez et al.2 reported an HIV-positive patient with secondary syphilis characterized by disseminated infiltrated plaques on the chest, back, neck, and face as well as axillar lymphadenopathy, closely resembling lymphoma. Furthermore, Dalmau et al.10 described an HIV-positive patient with secondary syphilis presenting as firm nodules on the tongue. In our case, in the absence of any clues from the patient’s history, the almost symmetrical distribution of the lesions was consistent with secondary syphilis.
Nodular lesions in syphilis have been thought to reflect a hypersensitivity reaction to Treponema pallidum and represent the transition to the tertiary phase of disease.7,8 Besides Kaposi sarcoma, the differential diagnosis of nodular lesions in our patient with HIV included a wide number of diseases, such as fungal and mycobacterial infections, lymphomas, and skin metastases as well as granulomatous disorders such as sarcoidosis.
Although there are limited data on treatment outcomes of syphilis in patients with HIV, higher rates of treatment failure have been reported.11 Limited data suggest that ceftriaxone can be used as an alternative to IV penicillin.3 Our patient was successfully treated with short daily infusions of ceftriaxone, 2 g daily, for two weeks with good tolerance. In all cases, close clinical and serological follow-up is required to exclude treatment failure.
Our observation suggests that the clinical presentation of syphilis may be particularly misleading in HIV-positive subjects and that a high degree of suspicion is warranted, even in the presence of features characteristic for other dermatoses such as in our case.
- 2Nodular secondary syphilis in a HIV patient mimicking cutaneous lymphoma. An Med Interna2004; 21: 241–243., , , et al.