A Case Report: Psoriasis-mimicking Lesions of Secondary Syphilis

in HIV Positive Patient

Vika Fintaru

, Sunardi Radiono

, Satiti Retno Pudjiati

Resident of Dermatology & Venereology Department, Faculty of Medicine, Public Health & Nursing, Universitas Gadjah

Mada/Dr. Sardjito General Hospital, Yogyakarta

Dermatology & Venereology Department, Faculty of Medicine, Public Health & Nursing, Universitas Gadjah Mada/Dr.

Sardjito General Hospital, Yogyakarta

Keywords: Psoriasis, secondary syphilis, HIV

Abstract: Syphilis is a sexually transmitted disease that is considered to be "the great imitator" because of the

clinical appearance that resembles various types of skin diseases. The coincidence between syphilis and

Human Immunodeficiency Virus(HIV) often occurs, and the incidence increases, especially in the male

population who have sex with men. Uncommon syphilis clinical manifestations are common in HIV

patients. This paper reports a 28-year-old man who was infected with HIV, came to Dr. Sardjito

General Hospital's Dermatovenereology polyclinic, with a complaint of scaly red plaques on the arms,

legs, hands, feet, and scrotum and accompanied by nail abnormalities that mimicking skin and nail

abnormalities in psoriasis. Histopathology examination appropriate with secondary syphilis with

psoriasiform acanthosis, neither hypergranulosis nor Monroe abscess, and many lymphocytes and

plasma cells infiltration in the upper dermis, perivascular, and periadnexa. The serological test showed

a positive result of Treponema Pallidum Haemagglutination (TPHA) and Venereal Disease Research

Laboratory (VDRL) 1/32. The patient was treated with injections of benzathine penicillin G 2.4 million

units single dose. Skin and nail lesions improvement occurred three months after therapy. Variable

clinical presentations of secondary syphilis in HIV disease may lead to wrong diagnosis and improper

treatment. The biopsy can be used to make a diagnosis of atypical syphilis lesions. Syphilis patients

with HIV infectionmore likely to experience serological declinefailure, recurrent infections, and slower

treatment response than patients who are not infected with HIV.

1 INTRODUCTION

Syphilis is a chronic sexually transmitted disease

caused by Treponema pallidum subspecies pallidum.

Syphilis can affect almost all of the internal organs,

including cardiovascular and nervous systems.

Transmission most often occurs through direct

contact with lesions in mucosa or skin during sexual

intercourse through vagina, anus, or genital. The

clinical manifestations of syphilis may resemble a

variety of diseases so often called "the great

imitator". (Zetola et al., 2002)

Syphilis prevalence in HIV patients is higher

than Human Immunodeficiency Virus (HIV)

negative patients. The coincidencebetween syphilis

and HIV often occurs because both are transmitted

primarily through sexual intercourse. (Karp et al.,

2009) Syphilis patients with ulcer lesions are at

higher risk of HIV infection than other syphilis

lesions. The high rates of coincidence of syphilis and

HIV make all patients with syphilis should be

offered HIV testing, and all HIV patients must

regularly undergo syphilis examinations, especially

for high-risk populations.

(Pastuszczak et al.,2011 )

According to World Health Organization

(WHO) data, there are around 900,000 new cases of

syphilis every year so the clinician must be aware of

the disease (Karp et al., 2009). Since 2014-2018,

Dr. Sardjito General Hospital has found 114 cases

of syphilis with 53 cases of syphilis coincidence

with HIV. This paper reports a case of psoriasis-

mimicking lesions of secondary syphilis in

homosexual patients with HIV.

Fintaru, V., Radiono, S. and Pudjiati, S.

A Case Report: Psoriasis-mimicking Lesions of Secondary Syphilis in HIV Positive Patient.

DOI: 10.5220/0009988103330337

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 333-337

ISBN: 978-989-758-469-5

333

2 CASE

A 28-year-old man came to the Dermatology and

Venereology Polyclinic of Dr. Sardjito General

Hospital Yogyakarta on May 2

, 2018

complainedred and scaly plaques, felt itchy on the

palms and feet soles since nine months ago. Plaques

also appeared on the back of the hands, instep,

forearms, legs, and scrotum. Two months before,the

patient said that there had been a painlessulcer and

untreated, but improved by itself. The skin around

the nails began reddishly, and there were pitting

nails. The patient did not have a previous similar

skin disease, and atopy history was denied. The

patient does not have serious illnesses or take

routine medication. The same complaint from the

family is also denied. The patient was diagnosed

with HIV since December 2015 and started taking

antiretroviral therapy(ARV) since January 2018

using fixed drug combination(FDC) tenofovir,

hiviral, and efavirenz with 162/ml CD4 count. The

patient had unsafe sexual intercourse with ten men,

insertive, and receptively.

On the physical examination, it was found

that the patient's condition was moderate, compos

mentis, all vital sign within standard limit and no

lymph nodes enlargement. Dermatological and

venereological status of palmar manus and plantar

pedis appeared diffuse erythematous plaques with

thick scales, on the arms, lower limbs, dorsum

manus, and dorsum pedis appeared erythematous

plaques with thick scales, multiple and scattered, on

the scrotum appearedscaleswith excoriation, and on

nails appeared periungual erythema, discoloration,

onychodystrophy and pitting nails were obtained

(Figure 1 and 2).

Figure 1: Dorsum manus: erythematous plaques with a

thick scaleon it, multiple, discrete

Figure 2: Dorsum manus (high magnification): periungual

erythema nails, discoloration, onychodystrophy and pitting

nails

Syphilis serological examination was performed

with a positive result of Haemagglutination

Treponema Pallidum (TPHA) and Venereal Disease

Research Laboratory (VDRL) 1/32 and patient was

HIV patient thus confirming the diagnosis of

secondary syphilis and coincidence with HIV. The

result of routine blood, liver function, kidney

function, and an electrolyte within reasonable limit.

Histopathological features of skin biopsy in the right

arm and right leg with hematoxylin-eosin (HE)

staining showed basket weave's type orthokeratosis,

psoriasiform acanthosis, spongiosis, minimal basal

cell vacuolar degeneration, and none of

hypergranulosis. For the dermis, patchy type of

inflammatory cell infiltration was obtained, mainly

lymphocytes and plasma cells in the upper dermis,

perivascular, and periadnexa (Figure 3A and 3B).

Histopathological results were in accordance with

secondary syphilis.

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

334

Figure 3: Histopathologic figures of secondary syphilis. A. basket weave's type orthokeratosis, psoriasiform acanthosis,

spongiosis, minimal basal cell vacuolar degeneration, and none hypergranulosis B. Highest magnification: many plasma

cells in the upper dermis

Diagnosis of psoriasiform type secondary

syphilis confirmed based on patient medical history,

physical examination, and histopathological

examination. Treatment was started with a single

dose of 2.4 million unit benzathine penicillin G. One

month after therapy, skin lesions and nails also

VDRL serological examination did not decline. Skin

and nail lesions improvement occurred in the 3

month after treatment, but VDRL was still 1/32 until

six months after treatment. In the 9

month after

treatment, there was a decrease in VDRL into 1/16.

Figure 4: after being given standard therapy, skin lesions

improved, subungual erythema, discoloration, an

onychodystrophy improved, there were still a few pitting

nails in digit II and III manus dextra

Figure 5: after being given standard therapy, skin lesions

improved, subungual erythema, discoloration, an

onychodystrophy improved, there were still a few pitting

nails in digit II and III manus dextra

3 DISCUSSION

Syphilis is a chronic infectious disease caused by

spirochete Treponema pallidum, a spiral-shaped

bacterium with two until three flagella at each end.

Syphilis spreads through direct contact with the

lesion, although a small part of infections spread by

blood transfer, for example, during blood

transfusions or sharing needles toinject the drug. The

growth of syphilis organisms is slow so that syphilis

has a long incubation period for about three weeks

from the appearance of initial (primary) lesions. This

disease is sexually transmitted only in the primary

and secondary stages. (Avelleira et al., 2006 ) There

is some evidence in the literature that shows

humoral and cellular immunityplays a role in

syphilis infection. CD4

T cells, helper T cells or

Th1 cell, play a role in cellular immunity and

produce cytokines that recruit lymphocytes and

other macrophages. CD8

T cell, cytotoxic cell or

Th2, play a role in humoral immunity and to activate

B cell. There is a hypothesis that helper T cells help

clear the chancre in early syphilis, so that for people

with weak cellular immunity, like HIV patients,

A Case Report: Psoriasis-mimicking Lesions of Secondary Syphilis in HIV Positive Patient

335

syphilis tends to develop to the secondary and

tertiary stages. (Avelleira et al., 2006)

Syphilis is divided into three distinct stages:

primary, secondary, and tertiary stages according to

clinical examination, patient medical history, and

time of infection. Primary syphilis lesion is solitary

red papule that forms a painless ulcer or chancre

within three weeks after exposure. (Lautenschlager,

2006)

HIV coinfection can be associated with several

chancres (up to 70% of patients) that are larger and

deeper than people who are not infected with HIV. ".

(Zetola et al., 2002)

Secondary syphilis lesions usually appear 6-10

weeks after healing of primary syphilis.

(Lautenschlager, 2006) Genital ulcer, in this case,

appeared two months before plaques on palms and

feet soles, possibly primary syphilis because lesion’s

base was clean, painless, cured without treatment,

and period of lesions appeared suitable to the period

of chancre before secondary syphilis lesions

appeared.

The manifestation of secondary syphilis is

generally a maculopapular exanthema or

papulosquamous with constitutional symptoms,

diffuse lymphadenopathy, and highly infectious skin

lesions. In the early stages of secondary syphilis, the

manifestations resolution of skin and lymph nodes

can occur without treatment. (Peeling et al., 2005)

Secondary syphilis lesions generally affect the palms

and feet soles, but about 75% of patients have

diffuse and symmetrical lesions. (Lautenschlager et al.,

2006) Sometimes there are a lot of thick scales that

give a form of psoriasis lesions. HIV-positive

patients present with more aggressive secondary

syphilis, accompanied by constitutional symptoms,

organ involvement, and atypical rash (karp et al

2009) Other typical clinical manifestations include

lichenoid, papulopustular, psoriasiform, vesicular or

corymbiform lesions (Gianfaldoni et a., 2017) Nail

involvement and periungual tissue changes are

reported can occur in syphilis secondary like

periungual edema, subungual hyperkeratosis,

discolorization, and onychodystroph (Liotta et al.,

2000) but no reports of pitting nails. Skin lesions in

this patient with periungual erythema,

discolorization, onychodystrophy, and pitting nails

mimicking psoriasis, but skin and nail lesions

improve with syphilis treatment so that differential

diagnosis of psoriasis can be ruled out.

Untreated secondary syphilis may get into a

latent stage where there are no clinical

manifestations, and the infection is only detected

through the serological examination. Individuals

with untreated latent syphilis, 15-40% develop into

tertiary syphilis and manifest cardiac or neurological

damage, severe skin or visceral lesions (gumma) or

bone involvement (Peeling et al., 2005) HIV

infection predisposes to neuro-ophthalmological

complications in syphilis patients with HIV

coinfection. Most patients with early syphilis who

have cerebrospinal fluid (CSF) abnormalities do not

show symptoms of the central nervous system, so

CSF analysis can help to confirm abnormalities.

Lumbar puncture and CSF analysis are currently

only recommended for the diagnosis of

neurosyphilis in individuals with appropriate clinical

syndromes, evaluating the possibility of treatment

failure, and for some patients with latent syphilis.

(Zetola et al., 2007; Pastuszcak et al., 2011) In this

case, we did not perform CSF examination because

there was no neurological abnormalities and

symptoms of ophthalmic, auditory, cognitive, motor,

or sensory deficits.

Patients had plaque-shaped lesions, and no ulcer

lesions that Treponema pallidum was not examined

under a dark-field microscope. Plaque lesions were

in accordance with the form of secondary syphilis

lesions so that syphilis serological examination was

performed. Serological examination in most people

infected with HIV is similar to patients who are not

infected with HIV. However, titers are too high or

too low, and false negatives can occur in some cases.

Several studies have shown that syphilis can cause a

transient increase in viral load, induce lymphocyte

and CD4 apoptosis, and a reduction in CD4 cell

count, which improves after the infection is treated.

Syphilis is estimated to increase 2 to 9-fold HIV

transmission.(Oh Y Kim et al., 2012)

Syphilis has diverse clinical and

histopathological presentations. The biopsy can be

used to make a diagnosis with atypical syphilis

lesions as the case above. The varied clinical

presentation of secondary syphilis, especially in HIV

disease, can lead to incorrect diagnosis and improper

treatment. Histology of secondary syphilis lesions is

generally obtained plasma cells infiltrates in

perivascular or diffuse with endothelial swelling and

vascular proliferation. Sometimes non-caseous

granulomas are found, basal cell vacuolar

degeneration, acanthosis, spongiosis or exocytosis of

lymphocytes. In addition, other features include

lichenoid inflammatory reactions (in lichen planus)

and/or psoriasiform patterns (a type of

psoriasis).(Palacios et al., 2007) Biopsy, in this

case, is obtained by plasma cells in the upper dermis,

perivascular, and periadnexa, with psoriasiform

acanthosis, so that they are appropriate with

secondary syphilis with psoriasiform patterns.

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336

Psoriasis is excluded because there is no Monroe

abscess, no hypergranulosis, andmany plasma cells

in the dermis.

Syphilis treatment in HIV positive patients and

HIV negative patients is not different. Benzathine

penicillin G 2.4 million intramuscular single-dose

units became first-line therapy for primary syphilis,

secondary syphilis, and early latent syphilis. For the

advanced latent syphilis, the patient will be given a

single dose of 2.4 million units of benzathine

penicillin G in 3 doses of 1-week interval. The

potential rate of failure and development of

neurosyphilis increases in HIV patients with syphilis

so nontreponemal titers should be examined at 1, 3,

6, 9, 12, and 24 months after treatment. If the

nontreponemal titer does not decrease 4-fold, there

is a 4-fold increase, or there are persistent signs or

symptoms or relapses, treatment is considered a

failure and can be repeated.

Pastuszczak et al., 2011;

Oh Y Kim et al., 2012)

Treatment, in this case, is in accordance with

standard treatment. Skin and nails lesions

improvement, such as discoloration and

onychodystrophy occurred in the 3

month after

therapy. Secondary syphilis lesions persist longer in

syphilis patients with HIV, which may be due to

more aggressive syphilis lesions and slower

response to syphilis treatment in HIV coinfected

patients. Syphilis patients with HIV are also more

likely to fail or slow down decline serological titers

and recurrent infections than HIV-uninfected

patients.

(Karp et al., 2009; Oh Y Kim et al., 2012)

This is in accordance with this case where the

decline of titers occurs in the 9

month after

treatment. Evaluation needs to be done at the 12

and 24

month after the initial treatment to ensure

there is no infection or failure of therapy in patients.

4 CONCLUSION

One case of secondary syphilis reported with

psoriasis-like lesions in 28 years old homosexual

men with HIV. Diagnosis confirms with

serological and histopathological examination.

Clinical improvement occurred at the 3

month

after treatment, and serological decline occurred at

ninth

months after treatment.

REFERENCES

Avelleira, C., Bottino, G. 2006. Syphilis: diagnosis,

treatment and control.An Bras Dermatol;81:111-26.

Gianfaldoni, S., Tchernev, G., Wollina, U. 2017..

Secondary Syphilis Presenting As Palmoplantar

Psoriasis.Open Access Maced J Med Sci.;5(4):445-7.

Karp, G., Schlaeffer, F., Jotkowitz, A., & Riesenberg, K.

2009. Syphilis and HIV co-infection. European

journal of internal medicine, 20(1), 9-13

Lautenschlager, S. 2006. Cutaneous manifestations of

syphilis. Am J Clin Dermatol.;7:291-304.

Liotta, A., Turiansky, W., Berberian, J.2000. Unusual

presentation of secondary syphilis in 2 HIV-1 positive

patients. Cutis ;66:383-6,389.

Mai, P., Whitney, A., Kyle. 2004. Secondary syphilis: a

histologic and immunohistochemical evaluation. J

Cutan Pathol. 2004;31:595–9

Oh, Y., Kim, H., Park, Y. 2012. A Case of Syphilis with

Nail Dystrophy. Korean J Dermatol;50:628-31.

Pastuszczak, M., Snarska-Drygalska, A., Wojas-Pelc, A.

2011. Syphilis and HIV infection – “a dangerous

combination”Dermatol Estet;1:362 5.

Palacios, R., Jimenez-Onate, F., Aquilar, M. 2007. Impact

of syphilis infection on HIV viral load and CD4 cell

counts in HIV-infected patients. J Acquir Immune

Defic Syndr. ;44:356-9.

Peeling, W., Hook, W. 2005. The pathogenesis of syphilis:

the Great Mimicker, revisited. J Pathol.;208:224–232

Zetola, M., Klausner. 2007. D.Syphilis and HIV infection:

an update. Clin Infect Dis.;44:1222-8.

Zetola, N., Engelman, J. 2007. Syphilis in the United

States: An Update for Clinicians With an Emphasis on

HIV Coinfection. Mayo Clin Proc. ;82(9):1091-1102

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