Diphasic fever with generalised rash including palm and sole
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A healthy man in his 30s presented with a 3-month history of fever and malaise. He reported high fever and generalised rash 3 months ago, and also reported similar symptoms 1 week ago. The patient was sexually active with men only. Medical history is significant for atopic dermatitis. He had no medications and allergies.

On physical examination, body temperature was 37.5 degrees, blood pressure was 122/62 mm Hg, pulse rate was 104/min and respiration rate was 16/min. A generalised rash including palm and sole was noted. Enlarged non-tender lymph nodes presented in the left cervical and both inguinal regions. Subsequent results of laboratory revealed positive treponema pallidum antibody haemagglutination test, rapid plasma regain test (titre 1:1024), treponema pallidum haemagglutination test (titre 1:2560) and HIV antibody test. The CD4+ cell count was 651 cells/mL and HIV RNA level was 5.1×10000 copies/mL.

Secondary syphilis and HIV coinfection was diagnosed. The patient was treated with amoxicillin 500 mg orally three times daily and fixed combination of bictegravir, emtricitabine and tenofovir alafenamide (BIC/FTC/TAF) one tablet orally once a day. Two weeks after treatment, high fever and rash improved.

Haematogenous dissemination of Treponema pallidum can lead to the various possible findings including dermatologic, neurologic and ocular manifestations. The characteristic rash is classically a diffuse, symmetric macular or papular eruption involving the entire trunk and extremities, including the palms and soles (syphilitic roseola). Syphilis and HIV coinfection may be more likely to present with severe cutaneous form. In high-risk groups such as men who have sex with men, physician should suspect sexually transmitted infections although syphilis and HIV coinfection present atypical symptoms, making diagnosis more difficult.

Source: https://casereports.bmj.com/content/13/10/e238013?rss=1