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A previously healthy 54-year-old bisexual man presented with a 2-week history of generalized nonpruritic skin rash and painless genital ulcerations. He reported low-grade fever, and admitted having unprotected sexual intercourse. Cutaneous lesions were present on the face, scrotum, trunk and extremities, including palms and soles. He had erythematous papular and nodular lesions and many of them were vesiculated or developed ulcerated necrotic centers with thick crust.
A serum rapid plasma reagin test (RPR) was positive at 1/8 with a TPHA reactive at 1/2560. Test for HIV was positive and CD4 count-cell was 497 cells/mm3. Skin punch biopsy confirmed by immunohistochemical stain the presence of spirochetes and the diagnostic of malignant syphilis (lues maligna) was made. The patient was treated with three doses of benzathine penicillin at weekly intervals and a Jarish–Herxheimer reaction was observed after the first doses. Malignant syphilis is a rare and severe variant of secondary syphilis and we should consider it in all HIV-infected patients with ulceronodular skin lesions.
Malignant syphilis is a serious and infrequent manifestation of syphilis in HIV patient with CD4 < 400. The most common symptoms are papulopustular skin lesions and fever. Serologic test for lues are positive in 100% of the cases and the treatment is penicillin [