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Autumn 2018, Vol. 26 No. 3

Hong Kong J. Dermatol. Venereol. (2018) 26, 162


Answers to Dermato-venereological Quiz

Answers to Dermato-venereological Quiz

CMT Cheung 張敏彤 and PCL Choi 蔡祥龍

  1. Clinical differential diagnoses include fungal infection (such as Cryptococcus, Penicillium), atypical mycobacterial infection, PLEVA, papulonecrotic tuberculid, exaggerated arthropod bite reaction, lues maligna, and eosinophilic folliculitis.
  2. Histopathological examination of the skin biopsy showed ulcerated skin covered by inflamed necrotic tissue with underlying upper dermal mixed inflammatory infiltrates. There is also dense superficial and deep perivascular and periadnexal plasma cell infiltrate. Treponema immunostain showed plenty of spirochaetes.
  3. The diagnosis is lues maligna. The patient's VDRL titre was 1:128. Lues maligna is a rare, severe cutaneous presentation of secondary syphilis, which is also known as malignant syphilis or ulceronodular syphilis. There is usually a prodrome of flu-like symptoms such as fever, headache, fatigue and myalgia, with subsequent development of necrotic ulcerative papules and nodules. The scalp and face are most commonly involved, but the lesions can be generalised. Most reported cases are associated with concurrent HIV infection.
  4. HIV-infected patients with syphilis should be treated with the same regimens as for those without HIV infection, and the treatment of choice is penicillin-based therapy. Due to the rarity of lues maligna, there are no large clinical trials to determine the optimal regimen. Reported treatment regimens in case reports include IV pencillin G for 14 to 21 days, and two to three doses of IMI benzathine penicillin at weekly interval. Regular monitoring of VDRL titre is of utmost importance for evaluating treatment response.