Malignant syphilis in an immunocompetent female
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The present case has been reported in the Indian Dermatology Online Journal.

A 35-year-old married woman presented with skin lesions, fever, malaise, and arthralgia for 3 weeks. Dermatological examination revealed; skin colored to erythematous macules, papules and nodules. The relatively older papules and nodules had developed crust, collaret of scale, and few had ulceration on surface.

The lesions were present all over the body with increased predilection for the extremities, trunk, face, genitalia, palm, sole, and scalp. She also had curdy white vaginal discharge sticking to her vaginal wall associated with itching suggestive of candidiasis. Rest of mucosal surfaces were free of any lesions. The inguinal, axillary, and cervical lymph nodes were 1.5 cm × 1 cm enlarged and nontender. Her husband denied history of extramarital sexual contact and was free of any skin and mucosal lesions suggestive of syphilis.

The hematological parameters were within normal limits. Her venereal disease research laboratory (VDRL) and Treponema Pallidum Hamagglutination Assay(TPHA) tests were reactive with titers 1:64 and 1:160 dilutions, respectively. Test for HIV was nonreactive. Her husband's VDRL test was reactive at 1:32 dilutions.

Histopathology of skin lesion from leg showed the presence of plasma cells in the vessel wall and thrombosed vessels in the dermis with endarteritis. Based on clinical, histopathological, serological, and associated systemic features, a diagnosis of lues maligna with vaginal candidiasis was made.

The patient was sensitive to test dose of penicillin and hence, she did not give consent for injectable penicillin. She was treated with Doxycyline 100 mg twice daily for 21 days for syphilis and fluconazole 150 mg stat dose for vaginal candidiasis.

The skin lesions of syphilis healed by 60% within 14 days of initiation of medication without Jarisch-Herxheimer reaction and vaginal candidiasis improved completely. The spouse also was treated with doxycycline 100 mg twice daily for 21 days, as he refused to give consent for injectable penicillin. Repeat serology of patient and her husband could not be done as both were lost to follow up.

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