A 49-year-old woman patient diagnosed with HIV Type 1 infection and cluster of differentiation 4 (CD4) count of 482 presented to the Dermatology Department at Groote Schuur Hospital, Cape Town, South Africa, with a four-week history of multiple crusted plaques, nodules, and ulcers on her face, arms, and abdomen (Figures 1 and 2). She was on antiretroviral therapy. Her past medical history revealed red painful eyes six months prior to this presentation. She did not seek medical care for her eye condition. She had generalized lymphadenopathy. no alopecia, no palmar-plantar, and no mucosal lesions or lesions of lues maligna. There were no features suggestive of secondary syphilis such as a papulosquamous nonitchy eruption on her body. Neurological examination was normal. Ophthalmological examination revealed unilateral acute papillitis. The physical examination showed a well looking female patient with crusted plaques and nodules on face and abdomen and an ulcer on her forearm, hence double morphology (Figures 1 and 2).
Our initial evaluation centered around lues maligna but this was excluded on the basis of the fact that lesions of lues maligna are usually multiple, well demarcated rupioid nodules and papules. A black eschar is sometimes observed on the lesions. Infections such as tuberculosis and deep fungal infections were also considered as atypical presentations are common in HIV infections. The patient was referred to an ophthalmologist and a diagnosis of papillitis was made. Rapid plasma reagin (RPR) test was positive (titer = 1 : 256, normal < 1 : 16). A diagnosis of tertiary syphilis with HIV coinfection was made. Tertiary syphilis diagnosis was made on the basis of the skin findings of gummas and papillitis, a manifestation of neurosyphilis. Lumbar puncture and skin biopsy were not done. She was treated with intravenous Penicillin G 5 MU IVI 6 hourly for 2 weeks. Healing occurred with atrophic scaring (Figures 3 and 4).