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Diphasic fever with generalised rash including palm and sole: secondary syphilis and HIV coinfection
  1. Hiroshi Yoshikawa,
  2. Kiyoshi Shikino,
  3. Yoji Hoshina and
  4. Masatomi Ikusaka
  1. General Medicine, Chiba University Hospital, Chiba, Japan
  1. Correspondence to Dr Kiyoshi Shikino; kshikino{at}

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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; he had a new sexual partner from 4 months ago. Medical history is significant for atopic dermatitis. He had no medications and allergies. On physical examination, body temperature was 37.5℃, 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 (figure 1). Enlarged non-tender lymph nodes presented in the left cervical and both inguinal regions. On laboratory tests, white bood cell (WBC) was 15 200/μL (24.0% neutrophils, 68.0% lymphocytes, 4.0% atypical lymphocytes), C-reactive protein was 0.39 mg/dL, aspartate aminotransferase (AST) was 165 U/L, alanine aminotransferase (ALT) was 264 U/L, lactate dehydrogenase (LDH) was 497 U/L, alkaline phosphatase (ALP) was 1661 U/L and γ-glutamyl transpeptidase (γ-GTP) was 321 U/L. 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 5.1×10 copies/mL. We diagnosed secondary syphilis and HIV coinfection. 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.

Figure 1

Diffuse, symmetric macular or papular eruption involving the entire trunk (syphilitic roseola).

We have described the case that presents acute HIV infection followed by secondary syphilis in healthy young man. When we see the patient with infectious mononucleosis-like syndrome, such as fever, rash and lymphadenopathy, we should consider HIV.1 2 Secondary syphilis developed within weeks to a few months after the primary infection. 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).3 Syphilis and HIV coinfection may be more likely to present with severe cutaneous form.4 Syphilis hepatitis is a rare clinical presentation of syphilis, it is found to be 9.7%. High serum ALP and γ-GTP levels with slight raised or normal serum transaminases and bilirubin are common.5 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.

Learning points

  • Syphilis and HIV have similar modes of transmission, and infection with one may enhance the acquisition and transmission of the other.

  • There is a high rate of HIV coinfection among MSM (men who have sex with men) with syphilis. Forty-two per cent of MSM with primary and secondary syphilis are HIV infected, compared with 8% of men who have sex with women and 4% of women.

  • High serum alkaline phosphatase and γ-glutamyl transpeptidase (γ-GTP) levels with slightly raised or normal serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) and bilirubin are common in syphilitic hepatitis.



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  • Contributors HY, KS, YH and MI managed the patient and revised the manuscript. HY and KS wrote the first draft.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Obtained.

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