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Finding Horses on a Zebra Hunt

Amarpreet Kaur and Stefan Law

September 7, 2017

A 53-year-old male with a history of compensated cirrhosis due to Hepatitis B presented with a 3-week history of fever, malaise, sore throat, and disseminated papular rash, including oral mucosal, plantar, palmar, and penile involvement (See Image 1). The patient noticed increased fatigue and a rash on his scalp. The rash then spread to his head and neck, down to his torso to his extremities including palms and soles. He presented to the emergency department 3 days prior to this admission and was evaluated by dermatology, where he received the diagnosis of Pityriasis lichenoides et varioliformis acuta (PLEVA), otherwise known as Mucha-Habermann disease. He was sent home with triamcinolone, cetirizine, and hydrocortisone cream with dermatology outpatient follow-up. When the rash continued to progress despite treatment, he presented to the emergency department again. Further history was negative for travel, joint pain, changes in medications, or illicit drug use. He admitted to having sex with men, including a new sexual partner 2 months prior, without use of condoms.

The patient appeared to be an anxious gentleman with a fever of 38.8 but otherwise normal vital signs. An ulcerated lesion was noted in his mouth. He had non-tender cervical and inguinal lymphadenopathy. His entire body, including palms and soles of his feet, was covered with an erythematous papular rash, which was non-blanching, painless, and without purulence (See Image 1). His abdomen was non-tender without hepatosplenomegaly. There was no penile discharge. His extremities were warm and well perfused. Cardiac, pulmonary, and musculoskeletal and neurologic exam were normal.

Blood samples were taken for HIV antibody, treponemal antibodies, and VDRL testing. HIV was negative. Treponemal antibody was positive with RPR titer >1:256. Skin biopsy was also performed, and an immunohistochemical study showed spirochetes within the epidermis and the superficial dermis (See Image 2). With this elevated titer, neurosyphilis entered the differential. Lumbar puncture was not performed since the patient had many lesions on his back and the risk for inoculation of his cerebrospinal fluid (CSF) with syphilis was considered too high. Comprehensive eye exam was normal. Given that the patient was HIV negative, had a normal eye exam, and no neurologic signs or symptoms, neurosyphilis was unlikely.2 Transthoracic echocardiogram (TTE) demonstrated a normal aorta. CT of the chest and abdomen were grossly normal. He was diagnosed with secondary syphilis and treated with a 3 weeks course of penicillin 2.4 MU weekly.

The patient developed fevers, myalgias, chills and a headache after the first dose of penicillin, thought to be secondary to Jarisch-Herxheimer reaction. He received supportive care with acetaminophen and fluids. At follow-up, the patient had symptomatically improved and all of the lesions resolved, with the exception of a few residual hyperpigmented lesions on his back and abdomen. He did not have other sequelae. Of note, his sexual partners were also treated.

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1. Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. Syphilis - 2015 STD Treatment Guidelines. June 4, 2015. Accessed November 6, 2015.

2. Centers for Disease Control and Prevention. STD Surveillance case definitions. 2014. Accessed on March 21, 2016.

3. Centers for Disease Control and Prevention (CDC). Primary and secondary syphilis among men who have sex with men--New York City, 2001. MMWR Morb Mortal Wkly Rep 2002; 51:853.

4. Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Surveillance. (Accessed on March 20, 2016).

Author information:

Amarpreet Kaur is a third-year resident in the Department of Internal Medicine at the University of Colorado – Denver and plans to pursue a fellowship in Pulmonary/Critical Care Medicine after residency.

Stefan Law is a Clinical Instructor and Fellow in Quality Improvement and Systems Leadership at the University of Colorado – Denver.