An overview of sexually transmitted diseases. Part III ... - Dermatology

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412 Czelusta, Yen-Moore, and Tyring J AM ACAD DERMATOL SEPTEMBER 2000 Fig 2. HIV-positive patient. Primary syphilis: perianal chancres. HSV thymidine kinase. 66 If resistance is suspected, HSV cultures and susceptibility testing are indicated. As such, the virus remains susceptible to foscarnet (which competitively blocks the pyrophosphate binding site of viral DNA polymerase) and cidofovir (which is a nucleotide analogue not dependent on viral thymidine kinase). 67 In cases of acyclovir resistance, intravenous foscarnet, 40 mg/kg of body weight every 8 hours, or topical cidofovir 1% applied to the lesions daily is suggested therapy from the CDC. 1 Foscarnet resistance has been reported, and this may make cidofovir the most viable option. 68,69 Regardless, these two medicines have important potential side effects. Foscarnet is nephrotoxic and can produce severe hypocalcemia, and in a phase I/II trial, topical cidofovir gel in concentrations of 3% and 5% was associated with local toxicity and delayed healing. 70 Syphilis. The interactions between syphilis and HIV gained widespread attention after a 1987 case series described HIV-infected patients whose syphilis infection was either refractory to appropriate thera- pies or displayed a rapid progression from primary syphilis to neurosyphilis. 71 Since this report, many investigators have studied the atypical features of syphilis in the setting of HIV disease, but the significance of these features remains unclear. Syphilis in the HIV patient appears to progress more rapidly through the clinical stages of syphilis, often will have an atypical clinical presentation, may have a refractory course after appropriate intramuscular penicillin, and may lead to unusual serologic test results (Fig 2). Numerous reports describe an accelerated progression through the syphilitic stages in HIV patients. 71-74 This progression may be related to level of immunosuppression; one study described HIV-infected patients initially presenting to physicians with undiagnosed secondary syphilis when their CD4 cell counts were less than 500 cells/mm 3 . 75 Others reported an association between accelerated ulcerating syphilis (malignant syphilis) and advancing HIV disease. 76,77 An association between advancing HIV disease and progression to neurosyphilis has also been noted. 76 In contradiction to these findings, Dowell et al 78 found no association between HIV stage and syphilitic progression or relapse after treatment. Although the clinical presentation is commonly the same in the HIV-infected host as it is in the otherwise healthy host, unusual features may be seen. The primary stage of syphilis may consist of multiple or more extensive chancres in the HIV patient. 79 Secondary syphilis affecting the immunocompetent host can present in a multitude of fashions, and likewise, the HIV patient can exhibit a wide range of cutaneous manifestations in this stage. Several reports document that patients with HIV are more likely to progress to neurosyphilis in the first 2 years after diagnosis, often despite appropriate therapy. 71-73,80-85 Unusual manifestations of neurosyphilis 86 have been documented in HIV-infected patients, as have unusual gummatous lesions. 87 Furthermore, rapidly developing cases of ocular syphilis 82,88,89 and syphilitic aortitis 90 have been reported in the HIV-infected population. Encephalitis and arteritis are other potential atypical presentations of syphilis in the HIV-infected host. For most people with coinfections of HIV and syphilis, laboratory tests can be interpreted as they would in an immunocompetent person. 1 However, atypical serologic responses in HIV-infected patients with syphilis do occur. Most reports involve falsepositive responses to the two nontreponemal screening tests: the rapid plasma reagin card test and the Venereal Disease Research Laboratory (VDRL) test. This sort of false-positive test is termed a “biologic false positive.” Several studies document an increased rate of biologic false positives in HIVinfected patients when compared with controls. 91-93
J AM ACAD DERMATOL VOLUME 43, NUMBER 3 In addition, one study noted an increased rate of biologic false-positive findings among those HIV patients who acquired their disease through intravenous drug abuse and in those who were coinfected with the hepatitis B virus (HBV), as compared with homosexual HIV-positive controls. 94 Other Czelusta, Yen-Moore, and Tyring 413 Fig 3. HIV-positive patient. Biopsy-confirmed, seronegative secondary syphilis. Fig 4. Photomicrograph of biopsy specimen of secondary syphilis shows dense lichenoid infiltrate with abundant plasma cells and histiocytes. abnormalities reported in serologic tests involve delayed titer responses after treatment of syphilis in HIV-infected patients. Typically, a patient’s biologic titers are expected to drop 4-fold after treatment. In HIV-infected patients, studies have documented both a normal serologic titer response after syphilis
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