Abstract
A 43-year-old female with no significant past medical history presented with fevers, night sweats, sore throat, generalized fatigue, and a progressive, tender, pruritic rash of 12 weeks. Exam revealed erythemato-violaceous plaques, patches, and subcutaneous nodules of the face, trunk, and bilateral extremities, sparing the palms and soles, as well as supraclavicular, axillary, and cervical lymphadenopathy, and tonsillar enlargement without exudate. Clinical presentation was highly suspicious for lymphoma cutis. A punch biopsy of a papule on the abdomen was performed and peripheral blood was sent for flow cytometry. Biopsy revealed scattered intraepidermal lymphocytes. The dermis displayed a superficial and mid, dense, nodular infiltrate of small lymphocytes and plasma cells. Lymphocytes were primarily CD3+ with an equal mix of CD4+ and CD8+ T-cells and fewer CD20+ B-cells. Flow cytometry only identified polytypic plasma cells. Immunohistochemistry for Treponema pallidum demonstrated numerous spirochetes. The patient was subsequently found to have a rapid plasma reagin titer of 1:64 and a positive human immunodeficiency virus (HIV) antibody/antigen test. The patients symptoms and rash resolved with administration of penicillin G benzathine and anti-retroviral treatment. Here, we describe a case of pseudolymphoma (PSL) as an initial presentation of secondary syphilis and HIV co-infection, mimicking lymphoma cutis both clinically and histologically. Four subtypes of PSL have been defined: nodular, pseudo-mycosis fungoides, intravascular, and other. In this case of nodular PSL, a dense lymphocytic dermal infiltrate suggested lymphoma cutis, though the abundance of plasma cells signaled the search for an alternative diagnosis. The incidence of syphilis and HIV co-infection is rising in the United States, and this case emphasizes the importance of maintaining a broad differential diagnosis and clinicopathologic correlation when initially suspecting cutaneous lymphoma.
Financial Disclosure:
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