Malignant syphilis

A 29-year-old woman, a known case of HIV, presented with a three-week history of fever and mucocutaneous lesions. Cutaneous examination revealed generalized scattered erythematous papules, with a necrotic eschar [Figure 1] and peripheral Biett collarette [Figure 2].

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Figure 1:

Multiple erythematous papules and plaques, some of them covered with a central necrotic eschar present on the trunk and bilaterally on the upper limbs

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Figure 2:

White rings of scales encircling a central erythematous crust (Biett collarette)

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HIV viral load was 4.95 log and total CD4 lymphocyte count was 23 cells/mm³. Tests for syphilis showed a positive result for rapid plasma reagin test (titre of 1:16), Treponema pallidum hemagglutination assay and enzyme immunoassay test, consistent with the diagnosis of malignant syphilis. A single dose of intramuscular benzathine penicillin 2.4 million units was administered and the lesions resolved within a month with residual scars. A Jarisch-Herxheimer reaction occurred, which resolved with antipyretics. Our case fulfilled the Fisher’s criteria except for the absence of high titre serologic test, due to prozone phenomenon.