Malignant syphilis (lues maligna) and concurrent infection with HIV

Malignant syphilis accompanied with neurosyphilis in a malnourished patient: A case report

BACKGROUND

Syphilis is a common sexually transmitted disease caused by the Treponema pallidum (T. pallidum). Malignant syphilis is a rare presentation of secondary syphilis. Here, we present a case diagnosed with malignant syphilis accompanied with neurosyphilis.

CASE SUMMARY

A 56-year-old man present with a 2-mo history of spreading ulcerous and necrotic papules and nodules covered with thick crusts over the face, trunk, extremities, and genitalia. The patient was diagnosed with malignant syphilis accompanied by neurosyphilis based on the characteristic morphology of the lesions, positive serological and cerebrospinal fluid tests for syphilis, brain magnetic resonance imaging, and histopathology, along with resolution of the lesions following the institution of penicillin therapy. The lesions and neurological condition successfully resolved after a course of treatment with penicillin.

CONCLUSION

We suggest that neurosyphilis should be considered whenever people have psychiatric symptoms without cutaneous lesions or human immunodeficiency virus.

Neurosyphilis is more common in malignant syphilis: A case series and review of the literature

Malignant syphilis is a rare skin manifestation of secondary syphilis, which has been reported primarily in the HIV-infected population. This study aimed to investigate the relationship between HIV infection, malignant syphilis, and neurosyphilis through a systematic chart review of 26 malignant syphilis patients seen at our hospital. We also performed a literature review of 83 reported malignant syphilis cases since 1987, when the first case of malignant syphilis co-infected with HIV was reported. We found there was no direct association between HIV infection and malignant syphilis or neurosyphilis. In contrast, we found that much higher proportion (30%) of malignant syphilis patients develop concurrent neurosyphilis compared to those with the common type of secondary syphilis (13.1%). Physicians should be aware of the fact that neurosyphilis is more common among patients with malignant syphilis and the importance of investigating for neurosyphilis in such patients.

Human immunodeficiency virus-positive secondary syphilis mimicking cutaneous T-cell lymphoma

Malignant syphilis or lues maligna is a severe form of secondary syphilis that was commonly reported in the pre-antibiotic era, and has now reemerged with the advent of the human immunodeficiency virus (HIV) epidemic. However, the characteristic histopathological findings of malignant syphilis remain controversial. The aim of this case report was to clarify the clinical and histopathological findings of HIV-positive malignant secondary syphilis. A Japanese man in his forties complained of fever, skin lesions, headache, and myalgia without lymphadenopathy during the previous 4 weeks. The skin lesions manifested as erythematous, nonhealing, ulcerated papules scattered on his trunk, extremities, palm, and face. Although the skin lesions were suspected to be cutaneous T-cell lymphomas on histological analyses, they lacked T-cell receptor Jγ rearrangement; moreover, immunohistochemical analyses confirmed the presence of spirochetes. The patient was administered antibiotics and anti-retroviral therapy, which dramatically improved the symptoms. On the basis of these observations of the skin lesions, we finally diagnosed the patient with HIV-associated secondary syphilis that mimicked cutaneous T-cell lymphoma. The patient’s systemic CD4+ lymphocyte count was very low, and the infiltrate was almost exclusively composed of CD8+ atypical lymphocytes; therefore, the condition was easily misdiagnosed as cutaneous lymphoma. Although the abundance of plasma cells is a good indicator of malignant syphilis on skin histological analyses, in some cases, the plasma cell count may be very low. Therefore, a diagnosis of malignant secondary syphilis should be considered before making a diagnosis of primary cutaneous peripheral T-cell lymphoma or lymphoma associated with HIV infection.

A case of rupioid syphilis masquerading as aggressive cutaneous lymphoma

Secondary syphilis has been known since the late 19th century as the great imitator; however, some experts now regard cutaneous lymphoma as the great imitator of skin disease. Either disease, at times an equally fastidious diagnosis, has reported to mimic each other even. It is thus vital to consider these possibilities when presented with a patient demonstrating peculiar skin lesions. No other manifestation of secondary syphilis may pose such quandary as a rare case of rupioid syphilis impersonating cutaneous lymphoma. We present such a case, of a 36-year-old HIV positive male, misdiagnosed with aggressive cutaneous lymphoma, actually exhibiting rupioid syphilis thought secondary to immune reconstitution inflammatory syndrome (IRIS).

Malignant syphilis in an AIDS patient

Malignant syphilis is an uncommon, but not unknown, ulcerative variation of secondary syphilis. The lesions typically begin as papules, which quickly evolve to pustules and then to ulcers with elevated edges and central necrosis. It is usually, but not mandatory, found in patients with some level of immunosuppression, such as HIV patients, when the TCD4(+) cell count is >200 cells/mm(3). Despite the anxiety the lesions cause, this form of the disease has a good prognosis. The general symptoms disappear right after the beginning of treatment, and lesions disappear over a variable period. This study reports the case of a 27-year-old man who has been HIV positive for 6 years, uses antiretroviral therapy incorrectly, has a TCD4(+) cell count of 340 cells/mm(3), a VDRL of 1:128 and itchy disseminated hyperchromic maculopapular lesions with rupioid crusts compatible with malignant syphilis.

Lues Maligna in a Chronic Alcoholic Patient

Lues maligna, which is characterized by noduloulcerative lesions, is a rare form of secondary syphilis. It is mainly seen in either HIV-infected or malnourished patients suffering from a depression in immunity. We presented a chronic alcoholic, HIV negative male patient with noduloulcerative lesions diagnosed as lues maligna based on his skin eruptions, results of serologic tests, and, histopathologic findings. We believe that chronic alcoholism could be the cause of immunosuppression in our case and wanted to emphasize the possibility of an association between lues maligna and chronic alcoholism.

Malignant syphilis with human immunodeficiency virus infection

Malignant syphilis or Lues maligna, commonly reported in the pre-antibiotic era, has now seen a resurgence with the advent of human immunodeficiency virus (HIV). Immunosuppression and sexual promiscuity set the stage for this deadly association of HIV and Treponema pallidum that can manifest atypically and can prove to cause diagnostic problems. We report one such case in a 30-year-old female who responded favorably to treatment with penicillin.

The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity

Syphilis has plagued mankind for centuries and is currently resurgent in the Western hemisphere. Although there has been a significant reduction of tertiary disease and recognition of facilitative interactions with human immunodeficiency virus infection, the natural history of syphilis has remained largely unchanged; thus, new strategies are required to more effectively combat this pathogen. The immunopathologic features of experimental syphilis in the rabbit; the course, stages, and pathology of human syphilis; and a comparison of human syphilis with leprosy suggest that the clinical course of syphilis and its tissue manifestations are determined by the balance between delayed-type hypersensitivity (DTH) and humoral immunity to the causative agent, Treponema pallidum. A strong DTH response is associated with clearance of the infecting organisms in a well-developed chancre, whereas a cytotoxic T-cell response or strong humoral antibody response is associated with prolonged infection and progression to tertiary disease. Many of the protean symptoms/appearances of secondary and tertiary human syphilis are manifestations of immune reactions that fail to clear the organism, due to a lack of recruitment and, more importantly, activation of macrophages by sensitized CD4 T cells. The Bacillus Calmette-Guerin vaccination can enhance DTH and has been shown to produce a low, but measurable, beneficial effect in the prevention of leprosy, a disease that shows a disease spectrum with characteristics in common with syphilis. In the prevention of syphilis, a potential vaccine protective against syphilis should be designed to augment the DTH response.

Pathologically confirmed malignant syphilis in an HIV-infected patient

We report a case of pathologically confirmed malignant syphilis in an HIV-infected patient. Physical examinations revealed ulceronecrotic skin lesions. Skin biopsies demonstrated syphilis spirochetes on immunohistochemical stain, and syphilis serological titers were positive. Treatment with intravenous penicillin G was begun, and complete resolution of the skin lesions was observed. A rapid plasma reagin titer test performed 3 months after treatment revealed a 4-fold reduction in the titer, indicating successful treatment.

Host defense mechanisms in secondary syphilitic lesions: a role for IFN-gamma-/IL-17-producing CD8+ T cells?

Cell-mediated immunity is thought to be of critical importance in antisyphilitic host defense, but the exact mechanisms are still unknown. This fact is particularly true for HIV-infected persons with a deficit in CD4+ T-cell number. We therefore obtained lesional skin samples from HIV+ and HIV- patients with secondary syphilis at different time points of lesional age to search both for causative microorganisms and to characterize the inflammatory infiltrate. By doing so, we detected Treponema pallidum spirochetes with a much greater abundance in late lesions of HIV+ individuals compared with the HIV- cohort. The dominating inflammatory cells were T cells, macrophages, and neutrophils at all stages and plasma cells in older lesions. In HIV- persons, T cells consisted of equal numbers of CD4+ and CD8+ T-cells, whereas in HIV+ patients, the majority of T cells belonged to the CD8 lineage and produced both IFN-γ and IL-17. Regulatory T cells and Langerhans cells were reduced in these patients compared with their HIV- counterparts. Because of our observations, we propose that T cells of both the CD4 and CD8 lineage are needed for an at least partial protective antisyphilitic immunity. Compensation mechanisms in HIV+ individuals, such as an increase of Tc1/17 cells as well as a reduction in immunoregulatory Langerhans cells and T cells, apparently do not overcome the deficiencies in these patients to eliminate the spirochete.

A case of late diagnostics of tertiary syphilis

The article describes a case of late diagnostics of tertiary syphilis affecting the musculoskeletal system in a patient who was under long-term supervision with a district general practitioner and who was diagnosed with thrombophlebitis. The diagnosis was verified only after the autotomy of the right lower leg

[Malignant syphilis in patients with human immunodeficiency virus (HIV)]

Malignant or noduloulcerative syphilis is an infrequent variant of secondary syphilis which appears in HIV+ patients. It is associated with fever, general malaise and skin lesions in the form of pustules or ulcerative scabs. Histology studies on the lesions show a perivascular infiltration of plasma cells and a formation of granuloma of giant and epitheloid cells. Most patients test positive for syphilis. We discuss the case of a 37-yar-old man who attended our service complaining of fever and scabby nodular lesions all over his skin. Blood testing confirmed that he had syphilis and HIV. The patient responded rapidly to penicillin treatment, with remittance of his fever. The skin lesions disappeared after 8 weeks. The rareness of malignant syphilis and its unusual clinical manifestation is a challenge to medical personnel. This diagnosis ought to be considered in HIV+ patients with fever and ulcerative skin lesions. Penicillin is the treatment of choice.

The many faces of secondary syphilis: a re-emergence of an old disease

There has been a recent dramatic re-emergence of syphilis in the UK. This article describes the varied clinical manifestations of secondary syphilis and describes the diagnosis and current guidelines for treatment, especially in association with human immunodeficiency virus infection.

Biological basis for syphilis

Syphilis is a chronic sexually transmitted disease caused by Treponema pallidum subsp. pallidum. Clinical manifestations separate the disease into stages; late stages of disease are now uncommon compared to the preantibiotic era. T. pallidum has an unusually small genome and lacks genes that encode many metabolic functions and classical virulence factors. The organism is extremely sensitive to environmental conditions and has not been continuously cultivated in vitro. Nonetheless, T. pallidum is highly infectious and survives for decades in the untreated host. Early syphilis lesions result from the host's immune response to the treponemes. Bacterial clearance and resolution of early lesions results from a delayed hypersensitivity response, although some organisms escape to cause persistent infection. One factor contributing to T. pallidum's chronicity is the paucity of integral outer membrane proteins, rendering intact organisms virtually invisible to the immune system. Antigenic variation of TprK, a putative surface-exposed protein, is likely to contribute to immune evasion. T. pallidum remains exquisitely sensitive to penicillin, but macrolide resistance has recently been identified in a number of geographic regions. The development of a syphilis vaccine, thus far elusive, would have a significant positive impact on global health.

A case of lues maligna in a patient with acquired immunodeficiency syndrome (AIDS)

We report a case of lues maligna (ulceronodular cutaneous syphilis) mimicking mycosis fungoides in an individual with AIDS and review the literature of this variant of syphilis in human immunodeficiency virus (HIV)-infected individuals. A comparison of the histological similarities and differences between lues maligna, late cutaneous syphilis and mycosis fungoides is also discussed.

Lues maligna

The incidence of syphilis in the UK is rising, particularly in HIV-positive men. We describe a Caucasian, HIV-negative woman who presented with secondary syphilis taking the form known as lues maligna. She also demonstrated the prozone phenomenon whereby the rapid plasmin reagin test was negative, but the Venereal Disease Research Laboratory and Treponema pallidum haemagglutination tests were positive.

Lues maligna in an HIV-infected patient

We report such a case of malignant syphilis in a 42-year-old HIV-infected man, co-infected with hepatitis B virus, who presented neurolues and the classical skin lesions of lues maligna. The serum VDRL titer, which was 1:64 at presentation, increased to 1:2,048 three months after successful therapy with penicillin, decreasing 15 months later to 1:8.

Secondary syphilitic lesions

An important theme that emerges from all early historical accounts is that in addition to the decreased virulence of Treponema pallidum, the incidence of secondary syphilis has decreased drastically over the past three centuries. Even in the early 20th century, most syphilologists were of the opinion that the disease had undergone changes in its manifestations and that they were dealing with an attenuated form of the spirochete. Such opinions were based primarily on the observations that violent cutaneous reactions and fatalities associated with the secondary stage had become extremely rare. The rate of primary and secondary syphilis in the United States increased in 2002 for the second consecutive year. After a decade-long decline that led to an all-time low in 2000, the recent trend is attributable, to a large extent, by a increase in reported syphilis cases among men, particularly homosexual and bisexual men having sex with men. The present review addresses the clinical and diagnostic criteria for the recognition of secondary syphilis, the clinical course and manifestations of the disease if allowed to proceed past the primary stage of disease in untreated individuals, and the treatment for this stage of the disease.

Syphilis bei HIV-Koinfektion. Syphilis with HIV coinfection

In recent years a rising incidence of syphilis has been observed, especially in the population of homosexual men. Because of altered sexual behavior in terms of increased promiscuity paralleled by decreased use of condoms and the fact that a syphilis infection increases the susceptibility to HIV coinfection, the incidence of HIV is also rising once again in this population. In patients with HIV coinfection, the course of syphilis is often atypical or dramatic. Stage-specific features suggesting coinfection include prolonged primary ulcers persisting well into the secondary stage, numerous atypical cutaneous findings in the second stage and a rapid progression from stage to stage. The diagnosis of syphilis may be more difficult because of false positive or false negative serological findings in patients with HIV coinfection. Whether or not the CNS is more often involved is this patient group has not been established by prospective studies and remains controversial. However, WHO and CDC recommendations include evaluation of the CSF in HIV-infected patients with either late syphilis or when the time course is unknown period. There is worldwide agreement on the therapy of syphilis in patients with HIV coinfection. Patients with early syphilis should be treated with 2.4 benzathine penicillin i.m. once or twice; patients with late syphilis, twice or three times. Patients presenting with clinical or serological signs of neurosyphilis require 18-24 million IU penicillin i.v. daily for at least 2 weeks.

Syphilis and HIV: a dangerous combination

HIV and syphilis affect similar patient groups and co-infection is common. All patients presenting with syphilis should be offered HIV testing and all HIV-positive patients should be regularly screened for syphilis. Syphilis agent may enhance the transmission of the other, probably through increased incidence of genital ulcers. Detection and treatment of syphilis can, therefore, help to reduce HIV transmission. Syphilis may present with non-typical features in the HIV-positive patient: there is a higher rate of symptomless primary syphilis and proportionately more HIV-positive patients present with secondary disease. Secondary infection may be more aggressive and there is an increased rate of early neurological and ophthalmic involvement. Diagnosis is generally made with serology but the clinician should be aware of the potential for false-negative serology in both primary and, less commonly, in secondary syphilis. All HIV-positive patients should be treated with a penicillin-based regimen that is adequate for the treatment of neurosyphilis. Relapse of infection is more likely in the HIV-positive patient and careful follow-up is required.

Cutaneous lesions of secondary syphilis are highly angiogenic

BACKGROUND

The role of angiogenesis in infectious processes is poorly studied. Some viruses have been linked to angiogenesis, but the role of bacteria and protozoa in inducing angiogenesis in chronic infections is poorly understood.

OBJECTIVES

We examined the role of angiogenesis in syphilis, a common and often difficult-to-treat infectious disease, especially in the setting of HIV/AIDS.

METHOD

Microvessel counts were performed on 27 paraffin-fixed sections of secondary syphilis by staining with monoclonal antibodies against CD31. In addition, immunohistochemistry was performed using antibodies against vascular endothelial growth factor (VEGF) to determine whether increased angiogenesis may be mediated, in part, through increased production of VEGF.

RESULTS

The CD31 mean microvessel count in secondary syphilis sections was significantly higher than in normal control sections. VEGF intensity appeared increased in the patients with secondary syphilis.

CONCLUSIONS

Infection with Treponema pallidum results in increased angiogenesis in secondary syphilis. The mechanism for increased angiogenesis may involve elaboration of angiogenic cytokines, such as VEGF and epidermal growth factor.

Mucocutaneous manifestations of secondary syphilis in north Indian patients: a changing scenario?

During the 1990s, no studies of various clinical presentations of syphilis have been published in the indexed literature. However, a change in the clinical profile of secondary syphilis was expected during the last decade with the rapid spread of the HIV epidemic. The objective was to study the mucocutaneous manifestations of secondary syphilis in patients attending the STD clinic at the Postgraduate Institute of Medical Education & Research Chandigarh, India, during the last decade and to compare them with other similar studies published during the 1980s. All patients who were diagnosed with secondary syphilis in our STD clinic from 1990 to 1999 were examined and investigated. Serological response was measured at 3, 6, 9, 12, and 24 months post-treatment or until serological negativity was reached. Fifty-three patients (males = 34, female = 19) during this period were found to have secondary syphilis. The most common symptoms were as follows-skin rash 38 (71.7%), lymphadenopathy 26 (49%), persistent chancre 4 (7.5%), nodular syphilides 2 (3.8%), lues maligna 2 (3.8%), patches in the oral mucosa 6 (11.3%), condylomata lata 14 (26.4%), split papules 2 (3.8%). Five patients had a thin and conspicuous genital scar of the healed primary chancre. Three patients were HIV seropositive (1 patient each with lues maligna, lichenoid, and nodular syphilides). With the spread of the HIV epidemic, atypical muco-cutaneous manifestations of secondary syphilis may be seen more frequently than before and may pose problems in diagnosis. In the present study, six patients had atypical manifestations, and three of them were HIV seropositive.

Malignant syphilis: a review

Syphilis is a disorder that may mimic many other diseases. Its incidence has risen and fallen over the centuries. A particularly malignant and virulent form, lues maligna, has recently been more frequently observed in the HIV-infected population. Raising the awareness of the occurrence of and the clinical and laboratory criteria of syphilis in general and lues maligna in particular in the HIV-infected population is becoming more urgent. Early treatment can result in a good outcome and stem the spread of the disease; as with other forms of syphilis, penicillin is the drug of choice.

Oral secondary syphilis in a patient with human immunodeficiency virus infection

This report describes a case of secondary syphilis in a patient with the human immunodeficiency virus (HIV) in whom the main clinical presentation of the disease was an extensive oral lesion. Few reports in the literature have focused on oral manifestations of syphilis in HIV-infected patients; most of these reports have dealt with a rare manifestation of secondary syphilis, the ulceronodular variety or lues maligna. However, in the case reported here the lesions were painless, smooth, white, oral plaques and papules on an erythematous base with a serpentine and reddish outline corresponding to the description of mucous patches. The differential diagnosis of this lesion may include oral squamous carcinoma, leukoplakia, erythroleukoplakia, candidosis, lichen planus, and granulomatous diseases. This case report emphasizes the importance of considering secondary syphilis in the differential diagnosis of oral lesions in HIV-infected patients, reinforces the importance of follow-up on the patient, and highlights the consideration for routine serologic testing for syphilis in all HIV-infected patients.