Thoracic sinuses in HIV a diagnostic dilemma

Introduction

HIV infection alters the presentation of common disease. Various infection may present together, in atypical forms or may occur recurrently.

Case Report

A 57-year-old man presented with multiple discharging sinuses on both sides of chest, multiple ulcers on back and painful ankylosis of right shoulder. There was an episode of ulcerating herpes zoster left-T6&7 dermatomes 3 months back. There was also evening rise of temperature and weight loss of 40% over a period of two months. There was severe pallor and edema of right upper limb. Examination of respiratory system showed decreased chest expansion and reduced breath sounds over right lung fields.

An ulcer of 8x5cms were present in left infraaxillary region; the floor of which was covered with slough and the margins were undermined. The skin in the vicinity was puckered, tender, and indurated. A solitary boggy swelling 30x10cms was present on right hemithorax with multiple discharging sinuses interspersed with scars too [Figure - 1]. Tenderness along ribs was present and significant was the absence of any crepitus. Multiple linear scars were present over left T6&7 dermatomes. Nails showed Beau′s lines and horizontal ridging with hyperpigmentation. Glans penis had a healed scar.

Haemoglobin was 3.9gm%, ESR was 130/mm at the end of one hour. Mantoux test was negative on repeated testing, VDRL was reactive in a high titer of 1:1028 and ELISA-HIV was positive. X-ray of chest showed few opacities of right lung field [Figure - 2] while X-ray of right shoulder showed soft tissue swelling and decreased joint space and sclerotic changes in the right clavicle, scapula and humerus.

Discussion

Multiple infections in patients with HIV is common knowledge. Alike to syphilis and tuberculosis - the master mimickers of any clinical conditions, HIV infection too is known to present itself with a variety of manifestations.[1] Altered CMI results in varied manifestation of tuberculosis. Rapidly progressive infection, Reactivation of latent infection and Atypical presentations are common. Anergy to tuberculin testing is well known.[3]

Co-existent syphilis and HIV are an interesting entity as they alter the course and manifestations of each other. Newer definitions like precocious tertiary syphilis have been since defined and there has also been resurgence of gummatous syphilis as well as neurosyphilis. Otologic syphilis is one of the few forms of sensorineural deafness and can be reversed if managed earlier.[2] A given patient with HIV is more likely to present with overlapping features of various stages of syphilis. Skin lesion may be characterized by more aggressive features like in malignant syphilis.

Serological tests for syphilis still remains the mainstay for diagnosing untreated syphilis in HIV patients. Very high titers of VDRL have also been reported in HIV patients without syphilis.[2]

Why gumma-syphilis/tuberculosis? A diagnosis of gummatous syphilis was considered as the patient had high VDRL reactivity on the background of HIV infection. Also present was the ulcer with features befitting a gummatous ulcer. Pulmonary features and radiological findings suggested a differential diagnosis of a tuberculous gumma. Alike features may also be seen in syphilis. Hence a consideration of gummatous syphilis was done.

HIV has thus rewritten clinical medicine whereby one may recollect the quote, "Uncommon presentation of a common disease is more common than the common presentation of an uncommon disease." Therefore HIV disease calls for a multidisciplinary approach. Our case thus poses a diagnostic dilemma.