Case and Research Letters
Malignant Syphilis in an Immunocompetent Patient
Sífilis maligna en un paciente inmunocompetente
F.J. García-Martínez
, V. Fernández-Redondo, D. Sánchez-Aguilar, J. Toribio
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Departamento de Dermatología, Complejo Hospitalario Universitario, Facultad de Medicina, Santiago de Compostela, Spain
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García-Martínez, V. Fernández-Redondo, D. Sánchez-Aguilar, J. Toribio" "autores" => array:4 [ 0 => array:4 [ "nombre" => "F.J." "apellidos" => "García-Martínez" "email" => array:1 [ 0 => "fjgarcia@aedv.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "V." "apellidos" => "Fernández-Redondo" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Sánchez-Aguilar" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Toribio" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Departamento de Dermatología, Complejo Hospitalario Universitario, Facultad de Medicina, Santiago de Compostela, Spain" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sífilis maligna en un paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1019 "Ancho" => 1276 "Tamanyo" => 284803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Round plaques with a squamous crust located on the trunk and lower limbs.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Malignant syphilis is a rare manifestation in secondary syphilis and one that is associated in most cases with immunosuppression.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 26-year-old man with a possible adverse reaction to penicillin. He consulted because of progressive lesions on the trunk, genitals, and lower limbs in the form of excoriated nonfollicular papules that were slightly painful. <span class="elsevierStyleItalic">Staphylococcus aureus</span> was isolated from the exudate from these lesions, so the patient was treated with topical mupirocin and later with oral erythromycin (500<span class="elsevierStyleHsp" style=""></span>mg/day for 14 days). Serology was positive for syphilis (positive rapid plasma reagin; <span class="elsevierStyleItalic">Treponema pallidum</span> hemagglutination assay [TPHA], 1/80), which was associated with a genital ulcer treated with oral erythromycin in primary care 1 year before the patient came to our clinic.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A month after starting the treatment that we prescribed, the patient reported acute worsening of the lesions. He presented with numerous intensely painful round plaques with raised borders and collarette scaling. Most of these plaques had very adherent necrotic eschars and central squamous crusts. The plaques were between 2 and 5<span class="elsevierStyleHsp" style=""></span>cm in diameter and were located on the scalp, trunk, genitals, and lower limbs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). For the last month the patient had also had evening fever and poor general condition.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Clinical differential diagnosis was made with cutaneous T-cell lymphoma.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A biopsy of one of the lesions revealed an acanthotic epidermis with areas of pseudoepitheliomatous hyperplasia covered by a squamous crust (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). In the dermis there was an intense perivascular lymphohistiocytic and plasma cell infiltrate with endarteritis and associated vascular occlusion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B and C).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Chest radiograph revealed no pleuropulmonary abnormalities. The complete blood count revealed a slightly elevated white blood cell count without left shift or lymphocytosis; serology for human immunodeficiency virus (HIV) and hepatotropic viruses was repeatedly negative. Ocular, neurological, and cardiac involvement and other cell-mediated immune disorders were ruled out. Serology for syphilis was strongly positive (VDRL test, 1/128; TPHA, 1/20 480), confirming the diagnosis of malignant syphilis in an HIV-negative patient. A sample of cerebrospinal fluid revealed no abnormal findings and allergy to β-lactams was ruled out by a skin prick test. We therefore started treatment with intramuscular injection of 7.2 million units of penicillin G benzathine in 3 weekly doses. Clinical response was rapid and without complications, with involution of all the lesions after 3 weeks.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Follow-up was performed at 3, 6, and 12 months. HIV serology was repeatedly negative, with stable titers at least 4 times lower (VDRL test, 1/32) than at the start of treatment. We plan to continue with follow-up visits, including serology, every 6 months for a period of 2 years.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Malignant syphilis is a rare form of secondary syphilis. Most of the cases reported in the last 20 years have been described in HIV-infected patients.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> This finding suggests a relationship between qualitative alterations in immunity and a more virulent course of the infection. However, it is paradoxical that most of these patients have a CD4 lymphocyte count above 200.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The relationship between HIV and syphilis is regulated by complex immunological mechanisms that are not well defined at present.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Other cases reported in HIV-negative patients had some immunological impairment due to alcoholism,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> hepatitis,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> or reinfection.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The 2010 guidelines of the Centers for Disease Control and Prevention (CDC)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> make no specific recommendation for malignant syphilis, with or without HIV seropositivity. The treatment for late latent syphilis is the most frequently used.</p><p id="par0050" class="elsevierStylePara elsevierViewall">For secondary syphilis in patients allergic to penicillin the CDC guidelines recommend oral treatment with doxycycline or tetracycline for at least 2 weeks. As in our case, the literature indicates a poor response to these drugs in malignant syphilis and proposes intravenous ceftriaxone as an alternative.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">.</span><a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Treatment with cephalosporins is inadvisable without first ruling out adverse cross-reactivity with β-lactams,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> so we consider it necessary to test for this allergy before treatment.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The latest data on the incidence of syphilis in Spain published by the Spanish Ministry of Health<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> show a great increase in cases in recent years, probably related to changes in sexual habits. Although notifiable diseases are not always reported, the number of reports of syphilis in Spain rose from 700 in 1998 to over 2500 in 2008 and 2009.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">These data suggest that malignant syphilis is an atypical form of a sexually transmitted infection that is becoming increasingly common in Spain. The increased incidence may be associated with unusual clinical manifestations that are difficult to diagnose.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Malignant syphilis should not be considered an opportunistic infection or one exclusive to HIV-positive patients<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> because it can occasionally occur in immunocompetent patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as. García-Martínez FJ, et al. Sífilis maligna en un paciente inmunocompetente. Actas Dermosifiliogr.2012;103:437-52.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1019 "Ancho" => 1276 "Tamanyo" => 284803 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Round plaques with a squamous crust located on the trunk and lower limbs.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1072 "Ancho" => 1500 "Tamanyo" => 509470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Epidermal hyperplasia with a superficial squamous crust (hematoxylin-eosin, x100). B, Prominent vessels with endarteritis and vascular occlusion (hematoxylin-eosin, ×250). C, Detail of intense inflammatory infiltrate with large numbers of plasma cells (hematoxylin-eosin, ×400).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sífilis maligna en un paciente con infección por el VIH" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L. Perez-Perez" 1 => "M. Cabanillas" 2 => "M. Ginarte" 3 => "D. Sanchez-Aguilar" 4 => "J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 12 | 24 |
| 2024 Octubre | 114 | 50 | 164 |
| 2024 Septiembre | 147 | 32 | 179 |
| 2024 Agosto | 174 | 59 | 233 |
| 2024 Julio | 158 | 49 | 207 |
| 2024 Junio | 164 | 49 | 213 |
| 2024 Mayo | 135 | 28 | 163 |
| 2024 Abril | 114 | 33 | 147 |
| 2024 Marzo | 112 | 39 | 151 |
| 2024 Febrero | 134 | 36 | 170 |
| 2024 Enero | 120 | 31 | 151 |
| 2023 Diciembre | 109 | 17 | 126 |
| 2023 Noviembre | 160 | 37 | 197 |
| 2023 Octubre | 134 | 39 | 173 |
| 2023 Septiembre | 135 | 35 | 170 |
| 2023 Agosto | 88 | 13 | 101 |
| 2023 Julio | 124 | 34 | 158 |
| 2023 Junio | 96 | 27 | 123 |
| 2023 Mayo | 272 | 32 | 304 |
| 2023 Abril | 249 | 21 | 270 |
| 2023 Marzo | 240 | 20 | 260 |
| 2023 Febrero | 182 | 22 | 204 |
| 2023 Enero | 136 | 28 | 164 |
| 2022 Diciembre | 164 | 34 | 198 |
| 2022 Noviembre | 78 | 26 | 104 |
| 2022 Octubre | 97 | 29 | 126 |
| 2022 Septiembre | 90 | 33 | 123 |
| 2022 Agosto | 57 | 42 | 99 |
| 2022 Julio | 82 | 32 | 114 |
| 2022 Junio | 42 | 22 | 64 |
| 2022 Mayo | 91 | 36 | 127 |
| 2022 Abril | 86 | 37 | 123 |
| 2022 Marzo | 71 | 59 | 130 |
| 2022 Febrero | 44 | 30 | 74 |
| 2022 Enero | 64 | 36 | 100 |
| 2021 Diciembre | 44 | 23 | 67 |
| 2021 Noviembre | 58 | 46 | 104 |
| 2021 Octubre | 55 | 50 | 105 |
| 2021 Septiembre | 53 | 35 | 88 |
| 2021 Agosto | 51 | 30 | 81 |
| 2021 Julio | 50 | 22 | 72 |
| 2021 Junio | 61 | 28 | 89 |
| 2021 Mayo | 53 | 34 | 87 |
| 2021 Abril | 105 | 51 | 156 |
| 2021 Marzo | 78 | 24 | 102 |
| 2021 Febrero | 71 | 42 | 113 |
| 2021 Enero | 39 | 19 | 58 |
| 2020 Diciembre | 31 | 14 | 45 |
| 2020 Noviembre | 20 | 26 | 46 |
| 2020 Octubre | 26 | 16 | 42 |
| 2020 Septiembre | 24 | 12 | 36 |
| 2020 Agosto | 29 | 21 | 50 |
| 2020 Julio | 27 | 16 | 43 |
| 2020 Junio | 37 | 26 | 63 |
| 2020 Mayo | 25 | 14 | 39 |
| 2020 Abril | 28 | 19 | 47 |
| 2020 Marzo | 31 | 25 | 56 |
| 2020 Febrero | 3 | 0 | 3 |
| 2020 Enero | 4 | 1 | 5 |
| 2019 Diciembre | 2 | 6 | 8 |
| 2019 Noviembre | 4 | 2 | 6 |
| 2019 Octubre | 0 | 1 | 1 |
| 2019 Septiembre | 4 | 4 | 8 |
| 2019 Agosto | 4 | 1 | 5 |
| 2019 Julio | 4 | 9 | 13 |
| 2019 Junio | 4 | 17 | 21 |
| 2019 Mayo | 4 | 24 | 28 |
| 2019 Abril | 2 | 16 | 18 |
| 2019 Marzo | 0 | 6 | 6 |
| 2019 Febrero | 9 | 1 | 10 |
| 2019 Enero | 1 | 4 | 5 |
| 2018 Diciembre | 8 | 0 | 8 |
| 2018 Noviembre | 8 | 0 | 8 |
| 2018 Octubre | 1 | 0 | 1 |
| 2018 Septiembre | 7 | 0 | 7 |
| 2018 Marzo | 1 | 0 | 1 |
| 2018 Febrero | 44 | 3 | 47 |
| 2018 Enero | 63 | 8 | 71 |
| 2017 Diciembre | 51 | 7 | 58 |
| 2017 Noviembre | 65 | 8 | 73 |
| 2017 Octubre | 53 | 7 | 60 |
| 2017 Septiembre | 44 | 13 | 57 |
| 2017 Agosto | 54 | 11 | 65 |
| 2017 Julio | 41 | 4 | 45 |
| 2017 Junio | 54 | 12 | 66 |
| 2017 Mayo | 46 | 6 | 52 |
| 2017 Abril | 75 | 13 | 88 |
| 2017 Marzo | 34 | 53 | 87 |
| 2017 Febrero | 69 | 8 | 77 |
| 2017 Enero | 42 | 3 | 45 |
| 2016 Diciembre | 67 | 7 | 74 |
| 2016 Noviembre | 88 | 7 | 95 |
| 2016 Octubre | 112 | 6 | 118 |
| 2016 Septiembre | 184 | 9 | 193 |
| 2016 Agosto | 154 | 6 | 160 |
| 2016 Julio | 47 | 14 | 61 |
| 2016 Junio | 16 | 0 | 16 |
| 2016 Mayo | 7 | 7 | 14 |
| 2016 Abril | 4 | 1 | 5 |
| 2016 Marzo | 10 | 0 | 10 |
| 2016 Febrero | 12 | 1 | 13 |
| 2016 Enero | 7 | 1 | 8 |
| 2015 Diciembre | 12 | 0 | 12 |
| 2015 Noviembre | 35 | 1 | 36 |
| 2015 Octubre | 23 | 3 | 26 |
| 2015 Septiembre | 9 | 4 | 13 |
| 2015 Agosto | 13 | 4 | 17 |
| 2015 Julio | 142 | 6 | 148 |
| 2015 Junio | 69 | 8 | 77 |
| 2015 Mayo | 92 | 6 | 98 |
| 2015 Abril | 87 | 10 | 97 |
| 2015 Marzo | 76 | 6 | 82 |
| 2015 Febrero | 85 | 9 | 94 |
| 2015 Enero | 85 | 15 | 100 |
| 2014 Diciembre | 84 | 10 | 94 |
| 2014 Noviembre | 68 | 10 | 78 |
| 2014 Octubre | 90 | 11 | 101 |
| 2014 Septiembre | 69 | 9 | 78 |
| 2014 Agosto | 68 | 13 | 81 |
| 2014 Julio | 84 | 19 | 103 |
| 2014 Junio | 109 | 15 | 124 |
| 2014 Mayo | 56 | 6 | 62 |
| 2014 Abril | 49 | 2 | 51 |
| 2014 Marzo | 36 | 12 | 48 |
| 2014 Febrero | 60 | 8 | 68 |
| 2014 Enero | 47 | 6 | 53 |
| 2013 Diciembre | 43 | 10 | 53 |
| 2013 Noviembre | 36 | 8 | 44 |
| 2013 Octubre | 26 | 6 | 32 |
| 2013 Septiembre | 28 | 7 | 35 |
| 2013 Agosto | 18 | 12 | 30 |
| 2013 Julio | 14 | 13 | 27 |
| 2013 Junio | 11 | 22 | 33 |
| 2013 Mayo | 13 | 16 | 29 |
| 2013 Abril | 10 | 14 | 24 |
| 2013 Marzo | 19 | 13 | 32 |
| 2013 Febrero | 39 | 6 | 45 |
| 2013 Enero | 48 | 5 | 53 |
| 2012 Diciembre | 34 | 5 | 39 |
| 2012 Noviembre | 0 | 4 | 4 |
| 2012 Octubre | 1 | 2 | 3 |
| 2012 Agosto | 3 | 3 | 6 |
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