Ulcerative syphilis (malignant syphilis) in a patient with human immunodeficiency virus infection. About a case

Syphilis is an infectious-contagious disease with a high prevalence worldwide, especially in homosexual patients and with a diagnosis of HIV. Its incidence is higher in Africa, Europe, the lower part of the Pacific West and the American continent, with the United States being the country with the most reported cases. (1) It is produced by the microorganism Treponema Pallidum subspecies Pallidum, belonging to the order of spirochetes, with a size of 6-9 microns, its transmission is sexual with lymphatic and hematogenous dissemination. (1,2)

Regarding the clinic, it is divided into an early stage which includes primary syphilis or hard chancre in which a single, painless, ulcerated lesion with limited edges and a clean bottom associated with inguinal adenopathies is evident; Secondary syphilis manifests as a maculopapular rash with palmoplantar involvement associated or not with systemic symptoms, elevated transaminases, nephrotic syndrome and aseptic meningitis. Latent syphilis is an asymptomatic stage of less than one year of evolution with positive serological tests. The early stage is the most contagious, but with less morbidity. (1) Finally, the late stage in which cardiovascular compromise is evidenced where the aorta is the most affected vessel, generating aortitis and endarteritis, bone involvement is mainly in the tibia, with periostitis in long bones, skin involvement in addition to the Syphilitic roseola are the gummas, these soft, necrotic lesions that can even appear in the central nervous system. Ophthalmological damage manifests as uveitis or retinitis and finally meningeal damage with neurophilis, syphilitic vasculitis and chronic meningoencephalitis (2, 5).

Malignant syphilis is a form of syphilitic secondaryism previously considered a manifestation of tertiary syphilis, first described in 1859 in immunocompromised people, however it was not until 1988 that it was designated a cutaneous manifestation in HIV-positive patients in whom lesions were found. ulcerated necrotic and crusted accompanied by systemic symptoms such as general malaise and fever with positive biopsies for leukocyte-clastic vasculitis with spirochetes in special stains (3).

Malignant syphilis is more prevalent in patients infected with HIV or with some degree of immunodeficiency whose incidence is unknown since the literature is scant, making it difficult to determine its frequency and pathogenesis. The first case reported was in a young man with HIV infection, however the immunological status of these patients seems not to be determined for the development of this entity given that 80% of the patients have more than 200 CD4 cells, which shows the relationship between Treponema pallidum with the HIV virus or a functional immunological defect but not a CD4 deficiency (6).

Clinically, it is distinguished by ulcerated papular and nodular lesions with a necrotic or hyperkeratotic surface with an ostraceous appearance, mainly affecting the trunk, extremities, followed by the face, palms, soles, and scalp, leaving varioliform scars, frequently associated with fever and symptoms. constitutional in cases of greater aggressiveness (6,7). Its differential diagnosis should be with other infectious dermatoses, mainly infections by the Herpes family virus, ecthyma gangrenosa, deep mycoses, mycobacteriosis and leishmaniasis, as well as dermatoses of lymphoproliferative origin such as cutaneous T-cell lymphomas, papulosis and lichenoid ptyriasis and others such as Reiter's syndrome (6,8).

The diagnosis of all stages, including malignant syphilis, is by measuring serological tests, among which we have treponemal tests, which are circulating IgG and IgM antibodies directed against the spirochete, are positive 2 weeks after acquiring the infection and are remain positive indefinitely; within these I know they have; the FTA ABS, EIA, CIA, TPPA. On the contrary, non-treponemal tests are IgG and IgM antibodies directed against lecithin, cholesterol and cardiolipin produced when the spirochete is destroyed. These tests are positive 4 weeks after infection, which are reported in dilutions and unlike treponemal tests. , become negative after treatment, examples of these tests are the VDRL (being the most sensitive in the CSF), RPR and TRUST. Since the latter are directed against lecithin, cholesterol and cardiolipin, we can find false positives in tests such as pregnancy, antiphospholipid syndrome, SLE (systemic lupus erythematosus) and even infectious causes such as malaria and brucellosis. They can also cause false negatives given the prozone effect secondary to the agglutination of Treponema in the sample (4).

The traditional diagnostic algorithm is by performing a non-treponemal test and in case of positivity it will be confirmed with a treponemal test, or the reverse algorithm can be performed starting with a treponemal test, if negative, infection is ruled out and in case of If positive, a non-treponemal test will be requested; if this is negative, we can say that it is a past syphilis or a prozone effect (3,4).

The histopathological diagnosis of malignant syphilis is variable, since spirochetes will not be obtained in all the samples, only in 40% of the cases, being similar to the findings in secondary syphilis. The epidermis can be visualized normal, with ulcers or necrosis, in the dermis an infiltrate of plasma cells, lymphocytes, histiocytes, lichenoid-type infiltrate, nodular, granulomatosis that can resemble sarcoidosis, as well as vasculitis (4). Ulcerated lesions could be caused by the affectation which can cause heart attacks in medium-caliber arteries. (7)

The classic diagnostic criteria are macroscopically and microscopically compatible skin lesions, high VDRL titers, and rapid clinical resolution with treatment. In those who have visual or neurological symptoms, a lumbar puncture should always be performed (7,8).

The treatment of choice for the early stages is benzathine penicillin at a dose of 2,400,000 IM in a single dose or ceftriaxone 1 g IV or IM for a total of 10 days. In patients with syphilis of indeterminate time, late latent, three doses of benzathine penicillin are required at a dose of 2,400,000 IM once a week or when there is involvement at the CNS, ocular or auditory level, crystalline penicillin will be started at a dose of 18-24 million each. 24 hours or continuous infusion for 14 days (6,8,9)