Dermatology: Practical and Conceptual


Image Letter  |  Dermatol Pract Concept 2021;11(2):e2021007 1

Dermatology Practical & Conceptual

Cutaneous Ulcers in an Untreated HIV Patient
Xavier Bosch-Amate1, Xavier Fustà-Novell1, Daniel Morgado-Carrasco1

1 Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Spain

Key words: cutaneous ulcers, syphilis, malignant syphilis, men who have sex with men

Citation: Bosch-Amate X, Fustà-Novell X, Morgado-Carrasco D. Cutaneous ulcers in an untreated HIV patient. Dermatol Pract Concept. 
2021;11(2):e2021007. DOI: https://doi.org/10.5826/dpc.1102a07

Accepted: August 5, 2020; Published: March 8, 2021

Copyright: ©2021 Bosch-Amate et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 
License BY-NC-4.0, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original 
author and source are credited.

Funding: None.

Competing interests: The authors have no conflicts of interest to disclose.

Authorship: All authors have contributed significantly to this publication.

Corresponding author: Daniel Morgado-Carrasco, MD, Dermatology Department, Hospital Clínic, University of Barcelona, Spain. Email: 
morgadodaniel8@gmail.com

Case Presentation

A 22-year-old man presented with a 6-month history of 

asthenia, anorexia, severe weight loss of 20 kg, low-grade 

fever, and cutaneous lesions that had occurred within 1 

month. More importantly, this patient presented with 

untreated HIV infection. Physical examination revealed 

a few erythematous and ulcerated plaques (some with 

necrotic crusts) on his trunk and extremities (Figure 1) and 

absence of lesions on mucous membranes, palms and soles. 

Blood tests showed 284 CD4/μL and HIV viral load 243,000  

copies/mL. Nontreponemal tests showed elevated VDRL 

titers (1/32). Lumbar puncture ruled out neurosyphilis. 

With a diagnosis of malignant syphilis, benzathine penicillin  

2.4 MU was administered intramuscularly with complete 

resolution of symptoms.

Figure 1. (A, B) Malignant syphilis. Erythematous and ulcerated plaques with well-demarcated borders on the left arm.



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Teaching Point

Syphilis has a broad spectrum of mucocutaneous mani-

festations. Malignant syphilis is a rare form of secondary 

syphilis, associated in most cases with HIV infection, that 

could present with a few cutaneous lesions. In our case 

histopathology was not done; however, it usually shows 

the presence of a dense inflammatory infiltrate, sometimes 

with a lichenoid pattern, with lymphocytes, plasma cells, 

and occasional presence of granulomas. Early detection 

of the coexistence of secondary syphilis and HIV infection 

is essential for correct management and the avoidance of 

serious complications [1,2]. 

References

1. Tucker JD, Shah S, Jarell AD, Tsai KY, Zembowicz A, Kroshinsky 

D. Lues maligna in early HIV infection case report and review of 

the literature. Sex Transm Dis. 2009;36(8):512-514. DOI: 10.1097/

OLQ.0b013e3181a2a946. PMID 19455078.

2. Fustà-Novell X, Morgado-Carrasco D, Barreiro-Capurro A, et al; 

Miembros del Grupo de Trabajo de Infecciones de Transmisón Sex-

ual del Hospital Clínic de Barcelona. Syphilis maligna: a presenta-

tion to bear in mind. Actas Dermosifiliogr. 2019;110(3):232-237. 

DOI: 10.1016/j.ad.2018.02.024. PMID 30098705.