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Middle-aged man with symmetrical lesions in his throat

Published:March 01, 2018DOI:https://doi.org/10.1016/j.ejim.2018.02.029

      1. Case presentation

      A 51-year-old man infected with HIV for more than 10 years visited our HIV clinic due to lesions in his throat. He had a CD4 T-cell count of >500 cells per μl and a HIV-RNA viral load of <20 copies per mm3. Nearly 3 months before this presentation, the patient participated in oral sex. At the clinic, he presented with a milky and (Fig. 1A ). He did not have any other symptoms on his skin.
      Fig. 1
      Fig. 1A milky and symmetrical mucosal erosion in the patient's soft palate (panel A).
      The patient's throat after 2 months of follow-up (panel B).
      What is the diagnosis?

      2. Diagnosis

      Answer: Butterfly sign of pharyngeal syphilis.
      The patient had a history of syphilis 4 years prior to this visit. Although he was treated with amoxicillin 4 years prior, his serological tests for syphilis (STS) titer had remained positive at a low level. Laboratory testing revealed that his rapid plasma reagin (RPR) test result increased from 1:4 to 1:512 (normal value, <1), and his Treponema pallidum hemagglutination (TPHA) level had increased from 1280 to >40,960 (normal value, <1).
      Co-infections of HIV and syphilis are common [
      • Imahashi M.
      • Izumi T.
      • Watanabe D.
      • Imamura J.
      • Matsuoka K.
      • Ode H.
      • et al.
      Lack of association between intact/deletion polymorphisms of the APOBEC3B gene and HIV-1 risk.
      ]. Notably, HIV patients often demonstrate prolonged STS positivity even after appropriate treatment. Thus, it is hazardous to diagnose syphilis solely based on a serological test. Pharyngeal syphilis accounts for 7% of syphilis cases [
      • Nishijima T.
      • Teruya K.
      • Shibata S.
      • Yanagawa Y.
      • Kobayashi T.
      • Mizushima D.
      • et al.
      Incidence and risk factors for incident syphilis among HIV-1-infected men who have sex with men in a large urban HIV Clinic in Tokyo, 2008–2015.
      ]. Due to the diversification of patients' sexual behaviors, healthcare providers should be aware of the oral manifestation of syphilis [
      • Dybeck Udd S.
      • Lund B.
      Oral syphilis: a reemerging infection prompting Clinicians' alertness.
      ]. The patient was treated with amoxicillin for a month, and the symptoms of pharyngeal lesions resolved rapidly. The picture shows the patient's soft palate after 2 months of follow-up (Fig. 1B).

      Conflicts of interest

      The authors disclose no financial or proprietary conflicts of interest with this publication.

      Consent

      Consent was obtained and no patient identifiers are evident on the clinical image.

      References

        • Imahashi M.
        • Izumi T.
        • Watanabe D.
        • Imamura J.
        • Matsuoka K.
        • Ode H.
        • et al.
        Lack of association between intact/deletion polymorphisms of the APOBEC3B gene and HIV-1 risk.
        PLoS One. 2014; 9e92861
        • Nishijima T.
        • Teruya K.
        • Shibata S.
        • Yanagawa Y.
        • Kobayashi T.
        • Mizushima D.
        • et al.
        Incidence and risk factors for incident syphilis among HIV-1-infected men who have sex with men in a large urban HIV Clinic in Tokyo, 2008–2015.
        PLoS One. 2016; 11e0168642
        • Dybeck Udd S.
        • Lund B.
        Oral syphilis: a reemerging infection prompting Clinicians' alertness.
        Case Rep Dent. 2016; 20166295920