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BRIEF ARTICLE

Syphilis in HIV Positive Individuals and the Importance of a
Skin Exam: A Case Report

Aditi Chokshi1, Amaury Diaz, MD2

1Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, FL
2Lee Memorial Hospital Department of Infectious Disease, Fort Meyers, FL

Despite advances in screening, diagnosis,
and treatment, the prevalence of syphilis has
been at a near historic high during the past
decade.1 Early recognition of characteristic
symptoms and treatment can curtail a larger
outbreak from occurring. Typical primary
syphilis is characterized by a single painless
lesion in the anal or genital region that
ulcerates to form a “chancre”. Progression to
secondary syphilis occurs within two to eight
weeks with appearance of a maculopapular
rash that can involve the palms and soles. If
progression to tertiary syphilis occurs,
patients can develop severe complications
such as gummas, aortitis, tabes dorsalis, and
argyll robertson pupils.2 Syphilis in HIV-
infected patients often has an atypical
presentation with higher rates of

asymptomatic primary syphilis and
accelerated disease progression.
Consequently, syphilis amongst HIV patients
often goes undiagnosed until it has
progressed to the secondary stage of
disease.3Secondary infection in HIV patients
is more aggressive with increased rates of
neurocognitive effects and ophthalmic
involvement.4

A 68-year-old HIV-positive male presented
with perianal painless erythematous lesions
for a 6-week duration. (Figure 1). He denied
a history of STDs or chronic diarrhea.
Previous treatment with antibiotics showed
no improvement. The patient went to his
primary care physician twice before receiving
a referral to a gastroenterologist to be

ABSTRACT

Among HIV-positive patients, co-infection with syphilis is estimated to be as high as 20%. The
diagnosis of syphilis is often missed due to its asymptomatic nature during its primary stages.
A 68-year-old HIV-positive male presented with perianal lesions to his primary care physician
twice. He was then referred to two different specialists before a proper physical exam was
conducted after which he was diagnosed with otosyphilis and neurosyphilis. Physicians
should have a higher index of clinical suspicion for syphilis in HIV-positive patients to allow for
prompt diagnosis given the propensity of these patients to develop more severe neurological
and ophthalmologic manifestations. This case highlights the importance of a thorough skin
exam by a primary care physician when examining patients to allow for an earlier and
accurate diagnosis and thus avoiding unnecessary referrals to specialists.

INTRODUCTION

CASE REPORT

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evaluated with flexible sigmoidoscopy and
biopsy. Pathologic evaluation showed
significant acute/chronic inflammation and no
malignancy. The patient developed further
symptoms of tinnitus and headache and was
treated with azithromycin with no
improvement. The patient was then referred
to an infectious disease specialist where a
generalized morbilliform macular rash was
observed. (Figures 2 and 3). An RPR yielded
a positive result, and the patient was
diagnosed with otosyphilis and neurosyphilis.
The patient was admitted to the hospital and
treated with 4 million units of IV penicillin G
Q4 for 14 days.

Figure 1. Clinical presentation of painless
erythematous perianal lesions.

Syphilis is known as “the great imitator” due
to its ability to mimic a myriad of other
diseases. The characteristic rash is non
pruritic and often has a superficial scale on
the lesions. This can result in misdiagnosis of
psoriasis in some patients. Other differential
diagnoses include pityriasis rosea, drug
eruptions, lichen planus and acute febrile
exanthems. Recognition of the unique palm
and sole lesions and morbilliform rash seen
in syphilis patients is crucial for early
detection and treatment.1 However, the

diagnosis is often not made until patients
have already developed more severe
complications. The recognition of the classic
maculopapular morbilliform rash associated
with syphilis is often not considered by
physicians who do not have specialized
training in evaluation of rashes.5

Figure 2. Characteristic maculopapular
secondary syphilis rash on trunk.

Figure 3. Secondary syphilitic lesions on flank.

Although serologic tests are considered the
mainstay of syphilis diagnosis,6 HIV-positive
patients could experience serological failure

DISCUSSION

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such as the prozone reaction compared with
HIV-negative patients.7 Therefore, clinicians
must rely on a thorough history, physical
exam, and high index of clinical suspicion to
facilitate a diagnosis.8 Several cases of
misdiagnosed syphilis in HIV patients have
been previously reported which further
emphasizes the importance of early
diagnosis.9-11

The patient discussed in this case visited his
primary care doctor with concerns regarding
his persistent perianal lesions. The primary
care physician prescribed prophylactic
antibiotics and had him return for a follow-up
visit. The primary care physician focused only
on the lesions around the anal region instead
of performing a thorough exam. Given the
high prevalence of coinfection of HIV and
syphilis and risk of more aggressive
diseases, physicians should take extra
precautionary measures to ensure diagnoses
are not missed. The patient was subjected to
an invasive procedure that yielded no
significant result and referred again to
another specialist. Ultimately, the infectious
disease physician noted the classic
maculopapular rash throughout the trunk,
arms, and back that resulted in a diagnosis.
This case emphasizes the importance of a
proper skin exam in each patient. If a proper
skin examination was performed, the patient
may not have progressed to otosyphilis and
neurosyphilis and required hospitalizations
along with medical bills from four different
specialists.

By increasing recognition of the characteristic
skin rash in patients, earlier detection and
treatment can be started to avoid
transmission to partners and further
increasing the surge in syphilis cases in the
United States.

This case emphasizes the importance of
training on recognizing characteristic rashes
and performing a thorough full-body skin
exam during each patient encounter.
Untreated syphilis can result in significant
patient mortality and morbidity. By increasing
the awareness of syphilis prevalence and
atypical presentations amongst HIV-positive
patients, physicians can prevent further
increase in syphilis cases and transmission
from patients to their partners.

Conflict of Interest Disclosures: None

Funding: None

Corresponding Author:
Aditi Chokshi
Nova Southeastern College of Osteopathic Medicine
Fort Lauderdale, FL
Email: chokshi.aditi00@gmail.com

References:
1. Clement, M. E., & Hicks, C. B. (2016). Syphilis on

the rise: what went wrong?. Jama, 315(21),
2281-2283.

2. Dylewski, J., & Duong, M. (2007). The rash of
secondary syphilis. cmaj, 176(1), 33-35.

3. German, M. N., Matkowskyj, K. A., Hoffman, R.
J., & Agarwal, P. D. (2018). A case of syphilitic
hepatitis in an HIV-infected patient. Human
Pathology, 79, 184-187.

4. Hernandez, I., Johnson, A., Reina-Ortiz, M.,
Rosas, C., Sharma, V., Teran, S., ... & Izurieta,
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5. Çakmak, S. K., Tamer, E., Karadağ, A. S., &
Waugh, M. (2019). Syphilis: a great
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6. Schmidt, R., Carson, P. J., & Jansen, R. J.
(2019). Resurgence of syphilis in the United
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7. Tong, M. L., Lin, L. R., Liu, G. L., Zhang, H. L.,
Zeng, Y. L., Zheng, W. H., … & Yang, T. C.
(2013). Factors associated with serological cure
and the serofast state of HIV-negative patients CONCLUSION

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with primary, secondary, latent and tertiary
syphilis. PLoS One, 8(7), e70102

8. Lynn, W.A., & Lightman, S. (2004). Syphilis and
HIV: a dangerous combination. The Lancet
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9. Seña, A. C., Zhang, X. H., Li, T., Zheng, H. P.,
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10. Chen, B., Peng, X., Xie, T., Jin, C., Liu, F., & Wu,
N. (2017). The tradition algorithm approach
underestimates the prevalence of serodiagnosis
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neglected tropical diseases, 11(7), e0005758.

11. Forrestel, A. K., Kovarik, C. L., & Katz, K. A.
(2020). Sexually acquired syphilis: laboratory
diagnosis, management, and prevention. Journal
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