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You are too brash if you ignore the rash
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  1. Madan Raj Aryal1,
  2. Paras Karmacharya2,
  3. Naresh Bhandari3,
  4. Anup Subedee4
  1. 1Department of Internal Medicine, Reading Health System, West Reading, Pennsylvania, USA
  2. 2Department of Internal Medicine, Reading Health System, Wyomissing, Pennsylvania, USA
  3. 3Department of Internal Medicine, St. Agnes Hospital, Baltimore, Marylaand, USA
  4. 4Department of Infectious Disease, Tulane university, New Orleans, Louisiana, USA
  1. Correspondence to Dr Paras Karmacharya, paraskarmacharya{at}gmail.com

https://doi.org/10.1136/bcr-2013-200506

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    Description

    A 42-year-old homosexual man with HIV AIDS presented with headache, neck pain and a new bilateral palmoplantar rash for 2 weeks. On examination, he had a temperature of 39.6°C and neck stiffness was noted. Maculopapular rash with some scaling was present on bilateral distal extremities, especially in the palmar (figure 1) and plantar surfaces (figure 2). Genital lesions were absent. A complete blood count was unremarkable. CD4 cell count was 287/μL. An MRI of the brain was unremarkable. Cerebrospinal fluid (CSF) analysis showed white cell count of 141/mm3 with lymphocytic predominance, protein 230 mg/dL and glucose 14 mg/dL. Gram-stain, acid-fast stain, India ink stain, cryptococcal antigen, PCR for herpes simplex and toxoplasma antibody tests in CSF were all negative. Given the palmoplantar rash and the CSF fluid findings, serological tests for syphilis were also ordered. Serum rapid plasma reagin was reactive at titre 1:1024 and florescent treponemal antibody-absorption(FTA-ABS) was positive. Venereal disease research laboratory (VDRL) in CSF was reactive (1:32). The patient was started on a 2-week course of intravenous penicillin and had rapid symptomatic improvement.

    Figure 1
    Figure 1

    Non-pruritic maculopapular palmar rash in a patient with syphilitic meningitis.

    Figure 2
    Figure 2

    Non-pruritic maculopapular plantar rash in a patient presenting with syphilitic meningitis.

    Neurosyphilis may present with widely variable presentations in different stages of syphilis and can be missed if non-neurological symptoms or signs of syphilis, ‘the great impostor’, are not recognised. It is important to recognise that meningitis can appear in early secondary syphilis, as it did in our case, as the earliest presentation of neurosyphilis.1 Diagnosis is confirmed with demonstration of VDRL or FTA-ABS titre in CSF.

    Learning points

    • It is important to recognise that meningitis can appear in early secondary syphilis, as it did in our case, as the earliest presentation of neurosyphilis.

    • A high index of suspicion as well as correlation with non-neurological symptoms or signs such as palmoplantar rash or epitrochlear lymph node enlargement which can be highly suggestive of syphilis would facilitate early diagnosis and treatment.

    • Diagnosis can be confirmed with demonstration of venereal disease research laboratory or florescent treponemal antibody-absorption titre in cerebrospinal fluid.

    Reference

    1. ↵
      1. Lichten GD,
      2. Pomeranz JR,
      3. Chester CS,
      4. et al
      . Secondary syphilis with acute meningitis and quadriparesis. J Am Acad Dermatol 1980;2013:388–92.
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    Footnotes

    • Contributors MRA and AS designed the case study and provided the logistics. PK and NB provided subsequent manuscript edits.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.