A male, heterosexual patient, diagnosed with HIV infection two years earlier, presented with pulmonary tuberculosis.
At that time, VDRL was negative and did not report any history of other sexually transmitted infections.
The patient completed anti-tuberculous treatment 3 months later with good response. At the beginning of treatment, the patient developed a viral load of 225441 cells, AIDS/ml, antiretroviral treatment (log 3.35) and a CD T lymphocyte count
The patient was hospitalized for presenting general malaise with intermittent fever, arthralgias, myalgias and disseminated cutaneous lesions, papule-non-ductal lesions and ulcerated lesions of three weeks in palms and extremities.
Some lesions were covered with crusts.
Examination of the oral, genital and anal mucosa showed no evidence of lesions; the neurological examination and evaluation were normal.
Initial laboratory studies showed: ESR 87 mm/first hour, white blood cell count 8,400/mm3 (neutrophils 59% and non-serum creatinine 29%), GOT 27 IU/l, GPT 25 IU/dl
The CD4 T lymphocyte count was 267 cells/mm3 and the plasma viral load was 2,543 copies/ml (log 3.41).
The scarification of one of the ulcerative-costal skin lesions showed a nonspecific inflammatory infiltrate, with negative Gram, Ziehl-Neelsen and Giemsa stains.
With a diagnosis of secondary malignant syphilis, a lumbar puncture was performed, obtaining CSF with normal, transparent pressure, proteins 41 mg/dl, glucorrhachia 55 mg/dl and 5 mononuclear cells.
The stains with India ink, Giemsa, Gram and Ziehl-Neelsen were negative.
The VDRL in CSF was non-reactive.
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A skin biopsy of one of the nodular lesions of the trunk was performed.
Histopathological study with hematoxylin-eosin staining showed an epidermis with parakeratosis, irregular acanthosis, intense lymphocytic exocytosis and abundant colloid bodies.
Dermis showed dense inflammatory infiltrates of subepithelial, perivascular and periadnexal arrangement consisting of lymphocytes, histiocytes and some plasma cells.
The histopathological diagnosis was interface dermatitis with liquenoid pattern and perivascular and perifollicular lymphoplasmacytic infiltrates.
The morphological findings described were compatible with the diagnosis of secondary lesions.
PAS, Ziehl-Neelsen and Warthin Starry stains were negative for microorganism identification.
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Treatment with benzathine penicillin 2.4 million IU IM once a week for 4 weeks was indicated.
Skin lesions resolved, evolving to hyperpigmented macules on the face, trunk and extremities of approximately 5 mm in diameter as sequel lesions.
No adverse events secondary to the indicated treatment were observed (Jarrisch-Herxheimer reaction).
At 6 months, VDRL had decreased its titration 4 times to 1:32, indicating an adequate response to the indicated treatment.
