Secondary Syphilis in a HIV positive patient masquerading as Reiter's Syndrome

摘要

Co-infection of syphilis and HIV is common, however a few cases present with features of active syphilis. HIV infection may alter the manifestations of syphilis and may present with unusual manifestations. We present a case report of secondary rupeiod syphilis in a HIV infected patient mimicking Reiter's Syndrome. A 28 year-old male of African descent presented with urethritis, arthritis and keratoderma blenorrhagica as well as a symmetrical psoriasiform eruption and circinate balanitis. He was recently seropositive for HIV. The patient was accurately diagnosed by using a combination of clinical findings, serology and histopathology. He was successfully treated with Benzathine penicillin. The significance of accurate diagnosis and treatment of a potentially fatal disease is described. Introduction Syphilis and human immunodeficiency virus (HIV) infections are frequently encountered in sexually transmitted infections (STI) clinic. Co-infection is not uncommon due to the similarities in transmission of the infections1, 2, 3. Syphilis is well known as a great mimic in clinical medicine. HIV-infected patients with secondary syphilis present with concomitant genitals ulcers more frequently4. The presentation of Syphilis may be altered by the presence of HIV infection due to abnormalities of the immune status resulting in unusual presentations rendering accurate diagnosis a challenge5. Reiter's syndrome typically presents as a triad of seronegative arthritis, nongonococcal urethritis and conjunctivitis associated with an antecedent genitourinary or gastrointestinal infection. Reiter's syndrome associated with HIV infection has also been reported6. Syphilis masquerading as Reiter's syndrome in a HIV infected patients is rare and fewer than five case reports are noted in the literature thus far1, 2. The significance of this entity lies in the accurate diagnosis and institution of appropriate treatment. Case report A 28 yr old male of African descent presented at our STI clinic with skin rash, genital ulcers and urethritis. He was diagnosed as positive for HIV infection two weeks prior to the presentation. The skin rash first appeared as small itchy papules on his face and in a month the rash spread widely to the neck, arms, trunk and lower limbs. The skin rash appeared as polymorphic eruption covered with silvery white scales (Fig.2). Bilaterally symmetrical thick hyperkeratotic lesions were present on the sole of the feet typical of Keratoderma blenorrhagicum (Fig 4). Palms showed only few scattered papules. He also had dysuria and urethral mucopurulent discharge during the same period. The uncircumcised penis was partially phimosed. Genital ulcers measuring 0.5x0.5cms were present on the glans penis and coronal sulcus mimicking circinate balanitis (Fig.1). Erythema and scaling were also noted on the glans penis. Thick scrotal plaques with scaling and foci of oozing associated pain were present. Nails and scalp were distinctly spared. His right knee joint was swollen and painful. There was no evidence of ocular involvement. Split papules at the angles of the mouth were present. Physical examination revealed bilateral inguinal adenopathy, and reducible left indirect inguinal hernia. Oral cavity revealed poor hygiene but no ulcers or mucosal patches were noted. Cardiovascular, respiratory, abdominal and neurological examination was within normal limits. The patient reported multiple sex partners and was addicted to Marijuana. He had tried herbal medicines before he presented to our clinic.Routine investigations: CBC – Hb: 11.4gm/dl, white cell count – 4600/μl, Platelet count –165,000//μl and urinalysis was normal. Urethral smear showed many pus cells, hence patient was treated with ceftriaxone 250mg Stat intramuscularly after test dose. Later culture from urethral swab was negative for gonorrhea. CD4 count was 235cells/μl. The viral load was 203,000 copies/ml. VDRL was positive at a titer of 1:256, and Microhemagglutation antibody test