2 week hx of lesion. VDRL and TPHA negative. Bisexual male. | Figure 1

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2 week hx of lesion. VDRL and TPHA negative. Bisexual male. 42 year old. no condom use.

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A 23‐year‐old man presented with a 2‐month history of recurrent fever and progressing skin ulcers with eschars on his face, trunk and extremities (a, b). Treponemal serology test was positive and immunohistochemistry of his skin biopsy showed numerous spirochetes (c, arrows). Additional results confirmed that he was infected with HIV, with a decreased CD4+ T‐cell count. A diagnosis of malignant syphilis associated with HIV infection was finally made. Malignant syphilis is an uncommon manifestation of secondary syphilis, characterized by generalized ulcerative skin lesions with prodromal symptoms. Generally, it occurs in immunosuppressed individuals, especially in HIV‐infected patients. Malignant syphilis may be the initial presentation of underlying HIV infection. The patient was treated with doxycycline 100 mg twice daily for 14 days as he was allergic to penicillin. The therapy resulted in rapid regression of the skin lesions (d), and antiretroviral therapy was initiated.


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Patient with history of severe mental illness (unpredictable mood, dementia-like symptoms) presents to PCP with no abnormal symptoms for routine physical and testing with STI screening. All tests came back as normal for blood work and negative for STI. \ 1 week later, the lab happened to be attempting validation for EIA Syphillus via analyzer. Patient's blood was pulled as a "known negative." Via this method, the patient presented as a strong positive on 10/10 repetitions. \ To rule out the possibility of a false positive via misperforming EIA, RPR was retested by 3 separate personnel, resulting in a confirmed negative screen and ruling out lab procrdural error. A confirmatory TPPA was performed afterward to confirm true negative. This, however, resulted in a positive reaction, confirming the reaction from the validation studies. \ This false negative RPR was later confirmed to be due to tertiary syphillus. It seems that all the stars aligned for the patient in order to finally reach a diagnosis. Sadly, any damage done up to this point is beyond reversible.

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