Malignant Syphilis With Generalized Necrotic Nodules in a Bisexual Patient With HIV Infection

Abstract

A 20-year-old bisexual male with multiple sexual partners presented with widespread erythematous patches, necrotic nodules, and crusts. Histopathological examination showed hyperkeratosis and neutrophil infiltration in the epidermis, with a band-like infiltrate of histiocytes, lymphocytes, and epithelioid cells in the dermis, with no evidence of malignancy. The patient tested positive for HIV and had a VDRL reactive titer of 1/128 and a TPHA reactive titer of 1:5120, confirming the diagnosis of lues maligna, a rare manifestation of secondary syphilis primarily seen in immunocompromised individuals. Treatment with Penicillin G Benzathine injections (2.4 million IU/week for 3 consecutive weeks) resulted in a Jarisch-Herxheimer reaction and significant clinical and serological improvement, with a fourfold decrease in VDRL titer to 1:32 at the three-month evaluation. This case highlights the need to consider lues maligna in the differential diagnosis of syphilis in HIV-positive patients and emphasizes the efficacy of Penicillin G Benzathine in its management.