Secondary Syphilis and HIV Co-infection:

A Case Series

Ade Fernandes, Dyatiara Devy, Damayanti, Evy Ervianti

Departement of Dermatovenereology Faculty of medicine, Universitas Airlangga / Dr.Soetomo General HospitalSurabaya

Keywords: Secondary syphilis, Co-infection, HIV

Abstract: The abstract should summarize the contents of the paper and should contain at least 70 and at most 200 wor

The interaction between syphilis and HIV infection is complex and a dangerous combinations. Atypical

nontreponemal serologic test results (i.e., unusually high, unusually low, or fluctuating titers) might occur

regardless of HIV-infection status. Despite several advances in the understanding of the interaction between

HIV infection and syphilis achieved during the past few years, the clinical treatment of coinfected patients

remains challenging. Clinically relevant differences in presentation, diagnosis, and management strategies

must be recognized by clinicians. The present communication describes two different cases of secondary

syphilis and HIV co-infection in young men, which shows difference in clinical manifestation and serological

response after treatment.

1 INTRODUCTION

Syphilis is a sexually transmitted diseasecaused by

Treponema pallidum subspecies pallidum. It has been

called the “great imitator” in reference to its ability to

cause a wide range of manifestations in nearly every

organ system. Men who have sex with men (MSM)

and bisexual men has the highest risk for syphilis

infection. Other significant risk factors include HIV

infection, thus coinfection is common, and the two

diseases affect each other in several ways. The

clinical manifestations of syphilis are divided into

primary, secondary, latent, and tertiary stages.These

coinfection may also alter the symptoms and signs,

theprogression of the disease, and the risk of

progressingto the tertiary stage.Studies have shown

that 16–30% of individuals who have had sexual

contact with a syphilis infected person in the

preceding 30 days become infected, and in some

cases the transmission rates may be much higher

(Holman et al., 2012; Mendoza et al., 2011).

Syphilis and HIV have played an important role

in public health. These two infections overlap,

interact, and share significant characteristics. A

recent review of studies conducted worldwide

reported a 9.5 % prevalence of syphilis among adults

living with HIV infection. In 2013, the incidence of

primary and secondary syphilis rose is 5.3 cases per

100,000 people in the US, more than doubling the

lowest rate of 2.1 per 100,000 in 2000. We report two

cases of secondary syphilis in MSM patient with HIV

coinfection. These cases reveal a specific

dermatological lesion of secondary syphilis and

confirmed by serological testing. This report

discusses about the clinical presentation, diagnosis,

treatment, and serological response.

2 CASE

Case 1 : 24-year-old male complained ofredness

maculeson his body, including the palm and soles for

1-month. The rash was neither painful nor pruritic. He

also complained of hair loss resulting in “moth eaten”

alopecia which occured simultaneously with skin

rash. One month before the rash appeared, he

hadulcer on his genitalwhich resolved without

treatment. His HIV infection was diagnosed in 2014

and had been sexually active with homosexual

partners since 2010From dermatological examination

onthoracalis anterior et posterior, scalp, palmar

manusdextra, plantar pedis dextra et sinistra region,

there weremultiple violaceous macule, sharply

marginated, vary in size, covered with thin scales.

There was the ‘moth-eaten’ syphilitic alopecia. There

was hyperpigmented macule, unsharplymarginated

on genital area. No evident lip or buccal mucosal

Fernandes, A., Devy, D., Damayanti, . and Ervianti, E.

Secondary Syphilis and HIV Co-infection: A Case Series.

DOI: 10.5220/0008157303550358

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 355-358

ISBN: 978-989-758-494-7

355

lesions were noted. The VDRL titer was 1:32 and

TPHA was 1:20480 with CD4 count of 88 cells/μl.

Case 2 : Thirty-three years old man came with

chief complaint multiple rash on his trunk and

extremities since 1 months before, painless and not

itchy. At first the lesion was found in his arms and

spreads to other site of body. Patient had multiple

sexual partner (bisexual), and there werehistory of

ulcer at his penis 3 months ago that healed

spontaneously in a few days. The patient diagnose

with HIV about 1 years ago and taking Anti

Retroviral (ARV) routinely. From dermatological

examination, on regio trunk and extremities superior

dextra et sinistra there were multiple eritematous

macule sharply marginated, 0,5-1 cm in diameter,

some covered with thin scale. The serology titer of

Venereal Disease Research Laboratory (VDRL) test

was 1: 128 and Treponema Pallidum

Hemagglutination Assay (TPHA) was 1:1280.

In these two cases, patient was treated with

Benzathine Penicillin G 2,4 million Unit

intramuscular single dose. Serologic examination was

reevaluated in 3, 6, 9 and 12 month after treatment. In

case 1 fourfold declined was achieved at sixth month

follow-up, but in case 2 serologic value still persist

until twelve month.

3 DISCUSSION

Syphilis infections have increased in recent years

internationally, especially among MSM. The surge in

syphilis among MSM is troubling, considering the

morbidity associated with untreated syphilis,

including neurosyphilis and cardiovascular sequele.

Furthermore, syphilis is associated with both HIV

transmission and acquisition, and a disproportionate

number of syphilis diagnoses occur in HIV infected

MSM (Petrosky et al., 2008).

Syphilis infection has been divided into primary,

secondary, latent, and tertiary stages. The clinical

manifestations of syphilis in HIV patients can be very

similar to those seen in an otherwise healthy host

(Mendoza et al., 2011).Clinical manifestation of

syphilis is not affected very much in HIV-infected

populations. Thus, the manifestation is almost similar

with those without HIV infection. However, there are

some differences which can be seen in HIV-infected

patients. As defined by CDC surveillance case

definitions, primary syphilis is a stage of syphilis

characterized by one or more chancres, in the

presence of laboratory evidence from tissues or sera

consistent with syphilis. At the inoculation site, a

chancre develops after an incubation period that

ranges from 10 to 90 days (average, 3 weeks) and is

associated with painless regional lymphadenopathy

arises 7–10 days after the chancre appears, especially

when the chancre’s location is genital. Unilateral

lymphadenopathy is more common earlier in the

course of disease, with bilateral involvement later in

the course. This chancre is a unique, firm, usually

painless, nonpurulent, indurated, round ulcer located

in the inoculation area. It initially presents as a small

papule that ulcerates very rapidly. Genital ulcers

primarily increase the transmission of HIV caused by

the loss of the epidermal barrier and local

inflammation. In HIV-positive patients, primary

syphilis can present with multiple ulcers that are

similar to herpetic lesions (soft chancre). These

lesions are deeper, persist longer, may leave a scar

upon healing, and may lead to perforations in the

prepuce or labia majora (Mendoza et al., 2011; Katz

et al., 2012; Wahab et al., 2013; Hu et al., 2014).

Secondary syphilis is a stage of syphilis

characterized by localized or diffuse mucocutaneous

lesions, often with generalized lymphadenopathy, in

the presence of laboratory evidence from tissues or

sera consistent with syphilis. Secondary syphilis,

which occurs in roughly onefourth of all untreated

syphilis cases, results from the multiplication of

disseminated T. pallidum and formation of lesions at

multiple sites in the skin and internal organs, despite

the presence of a significant antibody response.The

rashes are quite varied in appearance but have certain

characteristic features. The lesions are usually

widespread, involving the entire trunk and the

extremities, including palms of the hands and soles of

the feet, symmetrical in distribution, frequently pink,

coppery, or dusky red (particularly the earliest

macular lesions) usually 0.5–2 cm in diameterwith

involvement of the palms and soles. They are

generally nonpruritic, although occasional exceptions

have been reported (Das et al., 2015; Jansen et al.,

2016; Solomon et al., 2015).The diverse

manifestations of human syphilis also demonstrate

the invasiveness of T. pallidum. Secondary syphilis

presents after hematogenous dissemination from the

chancre has occurred, usually 4–10 weeks after

appearance of the primary chancre in the

immunocompetent patient. It usually manifests as

mucocutaneous lesions with systemic symptoms.

However, 75% of coinfected HIV patients present

with secondary syphilis while the chancre is still

present. Systemic symptoms include fever, anorexia,

muscle pain, depression, arthritis, and weight loss.

Without treatment, the secondary stage typically

recedes in 4–12 weeks (Mendoza et al., 2011).

these case, we noted that the patient presented with

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

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genital ulcer followed by rash on his body, palm and

soles simultaneously. This situation is observed more

common in HIV infected persons than those without

HIV.

The scalp may be involved, resulting in alopecia.

The eyebrows and beard area can be affected as well.

The ‘moth-eaten’ pattern is the most frequent clinical

manifestation of syphilitic alopecia (SA) and

represents one of the most characteristic signs of

secondary syphilis. In the event of suspected

secondary syphilis, the patient should be examined

for the presence of signs compatible with SA,

questioning about any perceived sign of hair loss or

alopecia and examining the scalp in the parieto-

occipital areas, where these signs are more frequently

observed. In case 1, the patient was having hair loss

with moth eaten pattern associated to syphilis

infection, which completely disappeared 8 weeks

after the end of the therapy (Mendoza et al., 2011;

Piraccini et al., 2015).

For most HIV infected persons, serologic tests are

accurate and reliable for the diagnosis of syphilis and

for following a patient’s response to treatment.

Regardless, both treponemal and nontreponemal

serologic tests for syphilis can be interpreted in the

usual manner for most patients who are coinfected

with T. pallidum and HIV. However, atypical

nontreponemal serologic test results (i.e., unusually

high, unusually low, or fluctuating titers) might occur

regardless of HIV-infection status.When clinical

findings are suggestive of syphilis but serologic tests

are nonreactive or their interpretation is unclear,

alternative tests such as biopsy of a lesion, dark-field

examination, and PCR of lesion material might be

useful for diagnosis (Waugh, 2015; CDC, 2015).

Persons with HIV infection and primary or

secondary syphilis should be evaluated clinically and

serologically for treatment failure at 3, 6, 9, 12, and

24 months after therapy. Increased risk of serological

failure has been reported to be more common among

those with late stage of syphilis and HIV-infected

patients (CDC, 2015).

In Case 1, VDRL titer declined

fourfold after 6 month completed therapy. However,

the subsequent follow up sample is needed for further

confirmation of this condition. Different with case 2,

the serologic test is fluctuated and at month-12 the

titer is not decrease to 4-fold.The subsequent follow-

up sample is needed for further confirmation of this

condition. Furthermore, the determination of the

immunocompromised state may be helpful to explain

this phenomenon.

The CDC guidelines for treatment of primary,

secondary, tertiary, and early latent syphilis less than

1 year in HIV patients are very similar compared to

those of HIV-negative patients. Most reports show

that HIV infection does not markedly affect response

to benzathine penicillin therapy. The U.S. Public

Health Service continues to recommend a single dose

of 2.4 million units benzathine penicillin in this

situation. Penicillin is the antibiotic of choice and it is

recommended antibiotic in HIV infected population

because it can reach high concentration in central

nervous system for treatment of neurosyphilis which

is more common in this population. Penicillin

remains not only the most effective treponemicide,

but it is easy to administer, has few side effects and is

relatively inexpensive. Results continue to be

excellent for all forms and stages of treponemal

disease, and there are no signs that T. pallidum has

developed resistance to this antibiotic Mendoza et al.,

2011; Wahab et al., 2013; CDC, 2015; Kinghorn et

al., 2016). In our case also, the treatment with a single

dose of 2.4 million units benzathine penicillin was

given according to stage of syphilis and patient

recovered well after the treatment by decreasing of

the rash on his body and regrowth of hair, but further

evaluation of serological test is needed.It is

recommended that attempts be made to identify, trace

and offer further investigation to at-risk sexual

contacts (Kinghorn et al., 2016).

4 CONCLUSIONS

The importance of our cases is not only about syphilis

and HIV co-infection but to highlight some of the

differences in clinical manifestations and serological

results of syphilis that might be important for

management of such patients.

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