Track

Abstract

Secondary syphilis is a notorious mimicker of diverse dermatoses and can present atypically in immunocompromised patients. We report a case of a 31-year-old transgender female with AIDS (CD4 count 84 cells/µL, CD4/CD8 ratio 0.12) who presented with a one-month history of diffuse, scaly, raised papular and verrucous plaques on the abdomen and arms. She reported subjective fevers, nausea, and weight loss but denied other systemic symptoms. Histopathology from a punch biopsy demonstrated epidermal hyperplasia with a lichenoid and psoriasiform pattern, featuring a dense band-like infiltrate of lymphocytes, histiocytes, and numerous plasma cells extending around superficial and deep vessels and adnexal structures. Special stains (PASD, GMS) and immunohistochemistry for Treponema pallidum were negative. However, serologic testing was strongly positive for syphilis (RPR titer 1:128; syphilis CIA reactive). This case highlights the importance of clinicopathologic correlation and serologic testing in diagnosing secondary syphilis, especially in patients with profound immunosuppression where histologic findings may be classic but direct organism detection is often negative. In individuals with HIV/AIDS, secondary syphilis may manifest with unusual and severe cutaneous presentations, complicating clinical recognition. Our findings underscore the need for vigilance in patients with atypical rashes and risk factors for sexually transmitted infections to ensure timely diagnosis and treatment.