Dr. Sushrut Save K.J. Somaiya Hospital & Research Centre, Mumbai
A 26 year old unmarried male student came with c/o Multiple, red lesions over the genital and perianal region, associated with itching and burning sensation, since 1 week H/O discharge of fluid from these lesions H/O multiple, mildly itchy, red raised lesions all over the body since 1 week H/O recurrent multiple, pus filled, asymptomatic lesions all over the body since 1 ½ months H/O blurring of vision since 2 weeks
H/O Rx taken: oral antibiotics, antifungal cream, with no relief H/O multiple unprotected sexual exposures with a single known partner since one year No h/o painless raw lesion over the genitals after sexual exposure No h/o discharge per urethra No h/o fluid filled lesions over genitals in the past No h/o drug abuse/ blood transfusions
Cardiovascular System : Normal Respiratory System : Normal Central Nervous System : Normal Per Abdomen : Soft, non tender
Split papules over the angle of the mouth
Greyish white patches over the hard palate
PROVISIONAL DIAGNOSIS
CBC: Hb 12.6 g/dl TLC 10,400/mm3 Plt -2.5 lacs/mm3 ESR: 50 mm/hour LFT: WNL RFT: WNL Urine examination: Trace proteins + HIV: Reactive for HIV 1 HbsAg: Non reactive RPR test: Reactive (1:128) TPHA: Reactive (1:1280) CD4 counts: 92 cells/ul HIV 1 Viral load: 93186 copies/ml Chest X-Ray normalchest X-Ray normal USG abdomen normal Mantoux test- ++ (12x13.5 mm)
Appearance Patient values Colourless, clear Normal values Proteins 11 mg/dl 15-45 mg/dl Glucose 59 mg/dl 50-80 mg/dl WBC count 4 cells/mm 3 Lymphocytes 100 % VDRL Non reactive Cytology No cells
Psoriasiform hyperplasia, parakeratosis with dense infiltrate of plasma cells through the dermis and endarteritis obliterans
Endarteritis obliterans
Plasma cell infiltrate
Necrotising pustular follicular reaction
Infiltrate of plasma cells and neutrophils
Vision: Rt eye 6/9 Lt eye 6/12 Fundoscopy: Vitreous haze present Optic disc normal
Dilatation of blood vessels at the periphery
FINAL DIAGNOSIS
Inj. Benzathine Penicillin 2.4 M.U. (1.2 M.U. IM in each buttocks) once a week for three weeks ART advised: Zidovudine, Lamivudine, Nevirapine
T. Prednisolone (40 mg) daily was started and tapered to 5 mg weekly and stopped Prednisolone acetate eye drops 4 times/day Homatropine eye drops twice a day
PRE TREATMENT POST TREATMENT ( After 5 weeks)
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Concomitant syphilis and HIV infection are particularly common among men who have sex with men, intravenous drug abusers, and commercial sex workers Syphilis increases the risk of HIV acquisition and onward transmission HIV infection may alter the natural history of syphilis: early progression to tertiary stage
Unusual cutaneous manifestations: Lues Maligna, pustular syphilid Neurological and ocular involvement have been reported more commonly in HIV infection especially in advanced immunosuppression Serological tests: normal to exaggerated to complete lack of immune response
Early and late syphilis Uveitis & Optic neuritis (M.C.) Acute posterior uveitis : acute syphilitic posterior placoid chorioretinitis ( ASPPC) Vitritis High incidence of neurosyphilis
1. Zetola NM, Engelman J, Jensen TP, Klausner JD. Syphilis in the United States: an update for clinicians with an emphasis on HIV coinfection. Mayo Clin Proc 2007;82(9):1091 1102. 2. Buchacz K, Patel P, Taylor M, Kerndt PR, Byers RH, Holmberg SD, Klausner JD. Syphilis increases HIV viral load and decreases CD4 cell counts in HIV-infected patients with new syphilis infections. AIDS 2004;18(15):2075 2079. 3. Narula T, Kamboj S, Martinez J, Engel LS. Co-infection: HIV and the great mimic syphilis. HIV Clin 2010;22(2):7 10. 4. Singh AE, Romanowski B. Syphilis: review with emphasis on clinical, epidemiologic, and some biologic features. Clin Microbiol Rev 1999;12(2):187 209. 5. Villaseñor-Park J, Clark E, Ho J, English JC 3rd. Folliculotropic nonalopecic secondary syphilis. J Am Acad Dermatol 2011;65(3):686 687
6. Tamesis RR, Foster CS. Ocular syphilis. Ophthalmology 1990;97:1281-7. 7. Barile GR, Flynn TE. Syphilis exposure in patients with uveitis. Ophthalmology 1997;104:1605-9. 8. Aldave AJ, King JA, Cunningham ET Jr. Ocular syphilis. Curr Opin Ophthalmol 2001;12:433-41. 9. Margo CE, Hamed LM. Ocular syphilis. Surv Ophthalmol 1992;37:203-20.