Case Report of Remarkable Coinfection in HIV Patient

Introduction

According to the WHO data in 2020, deaths due to syphilis in Myanmar reached 305 or 0.08% of total deaths. The age-adjusted death rate is 0.45 per 100,000 of population ranking Myanmar #62 in the world. ³ Syphilis has been termed the “great mimic” due to its versatile and varied disease presentations. Dermatological findings are associated with the secondary phase of the disease and typically consist of a generalized papular eruption that can involve the palms and soles, genitals, and mucous membranes. Despite minor differences, syphilis presents similarly in PLHIV and HIV-uninfected patients. In primary syphilis, PLHIV may present with chancre (up to 70% of patients) and with larger and deeper lesions (Approximately one-fourth of PLHIV present with concomitant lesions of both primary and secondary stages of syphilis at the time of diagnosis. ^4,5 Syphilis, like many other acute infections, causes transient increases in the viral load and decreases in the CD4 cell count that resolve after the infection is treated. ⁶ Secondary syphilis is followed by latent syphilis which is a period of relatively few symptoms and 25% of untreated patients in the latent stage will progress to tertiary syphilis. It is a stage characterized by cardiovascular and neurologic features which usually develops 10 to 30 years after initial infection. Regarding diagnosis, individuals with untreated HIV, serologic tests are more likely to be inaccurate. In such cases the serologic tests can be repeated at a later date and/or a skin biopsy can be performed. ⁷ Penicillin G, at a dose of 2.4 million units intramuscularly, is the recommended antibiotic in early syphilis. Treatment is followed by a reexamination at 6 and 12 months to ensure a reduction in nontreponemal antibody titer and thus to confirm a response to treatment. If no such reduction is seen, a follow-up course of benzathine penicillin will be needed.

Table 1. Suggested indications for CSF examination in patients with concurrent syphilis and HIV infection.⁷

Table 2. Recommended treatment and follow-up for syphilis in HIV-infected patients ⁷

Case report

A 58-year-old woman from Yangon presented to the Department of Tropical and Infectious Diseases, YGH with generalized skin rash for one month, fever for 3 weeks, productive cough and dyspnea for 1-week duration. On examination patient was febrile with SPO2 89% on air, BP 102/65mmHg with heart rate 120/min. There was maculopapular reddish brown skin rash all over the body involving palms and soles sparing mucosa areas. (fig 1) On auscultation, there were widespread crepitation on both left and right middle zones downward. Retroviral infection was confirmed with CD4 79/cell/mm³ and hepatitis B, C were negative. Investigations on admission revealed Hb 8.2 g/dl, Hct 43, MCV 69, WBC 7.2x 109/l, absolute neutrophil count 5.9×10⁹/l, absolute lymphocyte count 0.5x 10⁹/l, Plt 365 x 10³/ul, CRP 60 ug/ml, AST 50 U/L, ALT 26 U/L, GGT 43 U/L, serum bilirubin 7 umol/l, with normal renal function. Syphilis infection was found out to be positive VDRL 1/16 dilution with positive TPHA. Active Koch’s lung was detected on CXR (fig 2). and USG (abd) revealed intraabdominal lymphadenopathy. Urinary LAM was positive but other opportunistic infection like cryptococcal Ag, Toxoplasma Ab, sputum AFB gene Xpert, sputum PCP were all negative. No pathogenic organism was detected on sputum culture. During hospitalization, she became more breathlessness, pulmonary angiogram was proceeded and pulmonary embolism was detected in segmental lateral branch of left lower lobe pulmonary artery. She was finally diagnosed as secondary syphilis, active pulmonary tuberculosis complicated by pulmonary embolism with underlying retroviral infection (WHO stage 3). IV antibiotics were given for secondary bacteria infection and antituberculosis medications were also started according to body weight. IM Benzathine penicillin G 2.4 million units was given in a single dose. Anticoagulation therapy was started and plan for 6 months duration. She was clinically improved afterward and discharged after 4 weeks of hospitalization. She was planned to attend our infectious diseases clinic at YGH and planned to start ART on two weeks after anti TB treatment.

Fig.1 Secondary syphilis rash

Fig. 2 Chest X-Ray

Discussion

The first stage of syphilis, known as primary syphilis, is marked by the presence of a chancre, a well-demarcated, relatively painless, ulcerated lesion evolving from a papule with resolution within 3 to 6 weeks. Unilateral or bilateral inguinal adenopathy may also be present in primary syphilis. Our patient, however, did not exhibit any evidence of an active or healed primary chancre. Secondary syphilis has several systemic symptoms like headache, anorexia, weight loss, sore throat, and myalgia. Our patient presented with fever, cough and dyspnea due to associated active pulmonary tuberculosis. The most characteristic finding in secondary syphilis is that of a diffuse, papular rash that usually covers the torso, extremities, palms, and soles and it could be found in our patient. But secondary syphilis in patients with concurrent HIV may present with a broad spectrum of cutaneous morphologies, which include papulosquamous, lenticular, annular, and pustular lesions and those resembling eczema, leprosy, and mycosis fungoides ⁸. In patients with advanced HIV, secondary syphilis may also present as malignant secondary syphilis. This is characterized by severe ulcerating lesions and gummatous infiltration of mouth, eye, subcutaneous tissue, bone, joints, and cerebrospinal system ⁹. Thus, clinician should be careful to note that secondary syphilis is a disease that is more aggressive in HIV patients. Since our patient had no neurological features of syphilis, CSF examination was not proceeded and IM Benzathine Penicillin 2.4 million units was given according to WHO guideline. Non treponemal test(VDRL) was planned to check on 6 month of follow up and if titer is not response well CSF examination may be needed. Our patient presented with active Koch’s lung on CXR and anti-TB was given. But breathlessness was not improved so pulmonary angiogram was proceeded and pulmonary embolism was detected. According to studies in India, it is important to note that pulmonary tuberculosis became an emerging risk factor for thromboembolism.¹⁰ Therefore, clinician should be also aware of pulmonary embolism in treating pulmonary tuberculosis.

Conclusion

In conclusion, syphilis is one of commonly found coinfections in HIV patients. Dermatological manifestations of secondary syphilis in HIV patient can be varied in HIV patients. Moreover, like other infectious disease, syphilis can cause increase HIV viral load and decrease CD4 count in HIV disease course. Early and timely treatment can stop the progression of syphilis infection. Therefore, it is crucial for the clinicians to aware of various secondary syphilis rash and to test syphilis serology in treating HIV patient.

Reference

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Author Information

Aye-Mya-Theingi-Win¹, Khin-Rupar-Ko², Aye-Aye-Win³, May-Zabe⁴, Nyunt Thein⁵

1. Consultant physician, Tropical and Infectious Diseases Department, Yangon General Hospital
2. Professor, Tropical and Infectious Diseases Department, Yangon General Hospital
3. Associated Professor, Tropical and Infectious Diseases Department, University of Medicine (1), Yangon
4. Consultant physician, Tropical and Infectious Diseases Department, Yangon General Hospital
5. Senior Consultant physician, Former Head of Department of Medicine, Emeritus Professor of Medicine, University of Medicine (1), Yangon