International Journal of Infectious Diseases 18 (2014) 104–105
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Medical Imagery
Seronegative syphilis: another case for the great imitator§
A 42-year-old HIV-positive man (CD4 count, 29 cells/ml) developed an asymptomatic papulo-squamous eruption 1 week after beginning trimethoprim–sulfamethoxazole (TMP–SMX) (Figure 1). The eruption progressed despite discontinuation of
TMP–SMX. Three consecutive syphilis serologies (rapid plasma reagin) with dilutions and serum treponemal IgG antibody were negative. The patient was referred to the dermatology department. A lesional skin biopsy demonstrated a superficial and deep mixed
Figure 1. (A) Anterior trunk: thin, discrete erythematous papules with scale. (B) Palms: discrete, erythematous macules, many with a collarette of scale (panel B).
Figure 2. Lesional skin immunohistochemistry for Treponema pallidum demonstrating spirochetes.
§ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
1201-9712/$36.00 – see front matter ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.09.001
Medical Imagery / International Journal of Infectious Diseases 18 (2014) 104–105
105
Figure 3. Post-therapy: complete clinical resolution of the skin lesions at 6 months after the initial evaluation.
inflammatory infiltrate with numerous plasma cells. No mycobacterial or fungal organisms were identified by histochemical stains. Immunohistochemistry for Treponema pallidum using a red chromagen showed numerous spirochetes in the epidermis and dermis, confirming the clinically suspected diagnosis of secondary syphilis (Figure 2). Empirical therapy for syphilis had not been initiated due to a documented penicillin allergy. After diagnostic confirmation, a 4-week course of oral doxycycline 100 mg twice daily led to complete resolution of the eruption at 6 months (Figure 3). Syphilis seronegativity highlights a diagnostic challenge and has been reported in severely immunocompromised patients such as those with HIV.1,2 A high index of suspicion and decreased reliance on serologies for diagnosis and follow-up must be maintained for immunocompromised patients.1 Close clinical follow-up for evidence of treatment failure and/or recurrent disease is critical for seronegative patients diagnosed with syphilis.2,3 Conflict of interest: None to disclose. References 1. Hicks CB, Benson PM, Lupton GP, Tramont EC. Seronegative syphilis in a patient with the human immunodeficiency virus (HIV) with Kaposi sarcoma. Ann Intern Med 1987;107:492–5. 2. Fowler Jr VG, Maxwell GL, Myers SA, Shea CR, Livengood 3rd CN, Prieto VG, et al. Failure of benzathine penicillin in a case of seronegative secondary syphilis in a patient with acquired immunodeficiency syndrome: case report and review of the literature. Arch Dermatol 2001;137:1374–6.
3. Zetola NM, Klausner JD. Syphilis and HIV infection: an update. Clin Infect Dis 2007;44:1222–8.
Sareeta R.S. Parkera,b Christina Correntib Kathleen Sikorac Douglas C. Parkera,b,d,* a Grady Health System, Atlanta, Georgia, USA b Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA c Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA d Department of Pathology, Emory University Hospital, 1365 Clifton Road, NE, Atlanta, GA 30322, USA *Corresponding author. Tel.: +1 404 727 0666; fax: +1 404 712 9987 E-mail address: [email protected] (D.C. Parker) Corresponding Editor: Eskild Petersen, Aarhus, Denmark 3 August 2013 2 September 2013 3 September 2013
Contents lists available at ScienceDirect
International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid
Medical Imagery
Seronegative syphilis: another case for the great imitator§
A 42-year-old HIV-positive man (CD4 count, 29 cells/ml) developed an asymptomatic papulo-squamous eruption 1 week after beginning trimethoprim–sulfamethoxazole (TMP–SMX) (Figure 1). The eruption progressed despite discontinuation of
TMP–SMX. Three consecutive syphilis serologies (rapid plasma reagin) with dilutions and serum treponemal IgG antibody were negative. The patient was referred to the dermatology department. A lesional skin biopsy demonstrated a superficial and deep mixed
Figure 1. (A) Anterior trunk: thin, discrete erythematous papules with scale. (B) Palms: discrete, erythematous macules, many with a collarette of scale (panel B).
Figure 2. Lesional skin immunohistochemistry for Treponema pallidum demonstrating spirochetes.
§ This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits noncommercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
1201-9712/$36.00 – see front matter ß 2013 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. All rights reserved. http://dx.doi.org/10.1016/j.ijid.2013.09.001
Medical Imagery / International Journal of Infectious Diseases 18 (2014) 104–105
105
Figure 3. Post-therapy: complete clinical resolution of the skin lesions at 6 months after the initial evaluation.
inflammatory infiltrate with numerous plasma cells. No mycobacterial or fungal organisms were identified by histochemical stains. Immunohistochemistry for Treponema pallidum using a red chromagen showed numerous spirochetes in the epidermis and dermis, confirming the clinically suspected diagnosis of secondary syphilis (Figure 2). Empirical therapy for syphilis had not been initiated due to a documented penicillin allergy. After diagnostic confirmation, a 4-week course of oral doxycycline 100 mg twice daily led to complete resolution of the eruption at 6 months (Figure 3). Syphilis seronegativity highlights a diagnostic challenge and has been reported in severely immunocompromised patients such as those with HIV.1,2 A high index of suspicion and decreased reliance on serologies for diagnosis and follow-up must be maintained for immunocompromised patients.1 Close clinical follow-up for evidence of treatment failure and/or recurrent disease is critical for seronegative patients diagnosed with syphilis.2,3 Conflict of interest: None to disclose. References 1. Hicks CB, Benson PM, Lupton GP, Tramont EC. Seronegative syphilis in a patient with the human immunodeficiency virus (HIV) with Kaposi sarcoma. Ann Intern Med 1987;107:492–5. 2. Fowler Jr VG, Maxwell GL, Myers SA, Shea CR, Livengood 3rd CN, Prieto VG, et al. Failure of benzathine penicillin in a case of seronegative secondary syphilis in a patient with acquired immunodeficiency syndrome: case report and review of the literature. Arch Dermatol 2001;137:1374–6.
3. Zetola NM, Klausner JD. Syphilis and HIV infection: an update. Clin Infect Dis 2007;44:1222–8.
Sareeta R.S. Parkera,b Christina Correntib Kathleen Sikorac Douglas C. Parkera,b,d,* a Grady Health System, Atlanta, Georgia, USA b Department of Dermatology, Emory University School of Medicine, Atlanta, Georgia, USA c Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA d Department of Pathology, Emory University Hospital, 1365 Clifton Road, NE, Atlanta, GA 30322, USA *Corresponding author. Tel.: +1 404 727 0666; fax: +1 404 712 9987 E-mail address: [email protected] (D.C. Parker) Corresponding Editor: Eskild Petersen, Aarhus, Denmark 3 August 2013 2 September 2013 3 September 2013
