Clavi syphilitici–an unusual presentation of syphilis
Authors: Catarina Moreira, Ana F Pedrosa, Carmen Lisboa, Filomena Azevedo
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: The clinical manifestations of syphilis, often described as "the great imitator," are varied and may be neglected or confused with other diseases.1Domantay-Apostol G.P. Handog E.B. Gabriel M.T. Syphilis: the international challenge of the great imitator.Dermatol Clin. 2008; 26: 191-202Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Furthermore, in patients with human immunodeficiency virus (HIV), infections often exhibit unusual features.2Gregory N. Sanchez M. Buchness M.R. The spectrum of syphilis in patients with human immunodeficiency virus infection.J Am Acad Dermatol. 1990; 22: 1061-1067Abstract Full Text PDF PubMed Scopus (104) Google Scholar A 24-year-old man was referred to our department for a 6-month history of warty lesions on the palms and soles, unresponsive to keratolytic treatment. He reported having sex with men, 3 sexual partners during the past year, and inconsistent condom use. Latent syphilis and HIV infection had been diagnosed 4 years earlier after screening analysis and, at that time, he was appropriately treated with penicillin. Clinical examination revealed well-demarcated hyperkeratotic plaques and some erythematous macules and papules on the palms and on the soles (Fig 1). Exudative pink papules were observed on the scrotum and violet-brown macular plaques were present in the perianal region. A biopsy specimen of a palmar lesion demonstrated hyperkeratosis and a dermal polymorphic infiltrate with histiocytes, plasma cells, and lymphocytes. Warthin-Starry stain did not demonstrate microorganisms, but polymerase chain reaction was positive for Treponema pallidum in the skin lesion sample. Histologic examination of the perianal lesions was consistent with the diagnosis of condyloma acuminata. Routine laboratory tests were normal and tests for hepatitis A, B, and C were negative. HIV viral load was 50,990 copies/mL and CD4 cell count was 308 cell/mm3 (normal range: 500-1000 cells/mm3). A positive Venereal Disease Research Laboratory test (titer 1:32) and a reactive Treponema pallidum particle agglutination assay were obtained, supporting the diagnosis of secondary syphilis. Treatment was performed with a single intramuscular dose of benzathine penicillin (2,400,000 U). Rapid regression of palmoplantar and scrotal lesions was observed after the penicillin treatment (Fig 2). The patient underwent proctologic examination, which showed no further alterations in addition to perianal condyloma acuminata, and cryosurgery of those lesions was performed. The multiple and atypical manifestations of secondary syphilis in patients with HIV may result in a misdiagnosis and inappropriate treatment. In the literature, there are few reports of palmar and plantar hyperkeratotic lesions of secondary syphilis,3Kishimoto M. Lee M.J. Mor A. Abeles A.M. Solomon G. Pillinger M.H. Syphilis mimicking Reiter's syndrome in an HIV-positive patient.Am J Med Sci. 2006; 332: 90-92Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 4Shinkuma S. Abe R. Nishimura M. Natsuga K. Fujita Y. Nomura T. et al.Secondary syphilis mimicking warts in an HIV-positive patient.Sex Transm Infect. 2009; 85: 484Crossref PubMed Scopus (3) Google Scholar some of which can mimic and be confused with viral warts or calluses, classically known as clavi syphilitici.5Lewin G. Clavi syphilitici.Archiv für Dermatologie und Syphilis. 1893; 25: 3-34Crossref Scopus (2) Google Scholar In the described case, the combination of palmar-plantar lesions, detection of Treponema pallidum by molecular biology, positive serology for syphilis, and rapid response to treatment with penicillin was consistent with a diagnosis of secondary syphilis. We present this case to illustrate a rare and potentially confounding clinical manifestation of syphilis, a disease that is still very present in medical practice. We also intend to emphasize that the acquisition of another sexually transmitted infection (STI) by a patient with HIV is a public health problem because it means the maintenance of risk behaviors that enhance the transmission of these diseases. For the patient, the infection with an STI is a risk factor for other STIs, so in individuals with HIV, syphilis should be included in the differential diagnosis of new skin and mucosal lesions or those unresponsive to conventional therapy.