Ulceronodular syphilis (lues maligna praecox) in a person newly diagnosed with HIV infection

Abstract

In this case of secondary syphilis, pustular lesions progressed rapidly to painful ulcerative lesions in a patient with early HIV infection. This rapidly progressive form of early syphilis has historically been called lues maligna praecox, a severe form of noduloulcerative secondary syphilis. Serologic tests for syphilis were positive and biopsy showed forms consistent with Treponema pallidum in the lesions. This case demonstrates how HIV infection may affect presentation and diagnosis of secondary syphilis.

Figure 1

The face (left mandible) is a typical location for ulcerative syphilides.

Figure 2

The ulcerative syphilide at the gluteal fold appears in the distribution of condyloma lata (kissing lesions).

Figure 3

Low power view shows subtotal epidermal ulceration and a dense mixed inflammatory infiltrate within the superficial and deep dermis.

Figure 4

High power view illustrates reactive endothelial cells and scattered plasma cells, eosinophils and neutrophils within a dense lymphohistiocytic inflammatory infiltrate.

Figure 5

Immunohistochemical stain directed against spirochetes reveals numerous corkscrew-shaped microorganisms, consistent with the morphology of T pallidum.