A 21-year-old man with stage-A2 human immunodeficiency virus infection well controlled with Genvoya (elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide) complained of loss of follicular density affecting his eyebrows and lashes (Fig. 1) noticed 2 weeks earlier. A generalized asymptomatic rash had appeared recently. He also reported high-risk sex with men (on average, 5 partners per month). A physical examination revealed patchy alopecia only on the eyebrows and lashes. Erythematous, scaly maculopapular lesions were seen on the trunk. Similar lesions were found on the palms and soles, but scaling was at the periphery. The patient had not noticed any genital ulcers within the past few weeks. Suspecting syphilis, we ordered serology and administered a single dose of 2400000 IU of penicillin G (benzylpenicillin). The diagnosis of syphilis was confirmed a week later by enzyme-linked immunosorbent assay and reactive rapid plasma reagin and Treponema pallidum hemagglutination tests (at dilutions 1:32 and 1:10240, respectively). Appropriate early treatment usually leads to full recovery within 8 to 12 weeks, and this occurred in our patient. Syphilis should be included in the differential diagnosis when patients who are young or at high-risk for syphilis are found to have the signs and symptoms described in this case.

Figure 1

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