array:24 [
  "pii" => "S0365059622001295"
  "issn" => "03650596"
  "doi" => "10.1016/j.abd.2021.11.003"
  "estado" => "S300"
  "fechaPublicacion" => "2022-09-01"
  "aid" => "591"
  "copyright" => "Sociedade Brasileira de Dermatologia"
  "copyrightAnyo" => "2022"
  "documento" => "article"
  "crossmark" => 1
  "licencia" => "http://creativecommons.org/licenses/by/4.0/"
  "subdocumento" => "crp"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:1 [
    "total" => 0
  ]
  "Traduccion" => array:1 [
    "pt" => array:19 [
      "pii" => "S2666275222001564"
      "issn" => "26662752"
      "doi" => "10.1016/j.abdp.2022.07.018"
      "estado" => "S300"
      "fechaPublicacion" => "2022-09-01"
      "aid" => "591"
      "copyright" => "Sociedade Brasileira de Dermatologia"
      "documento" => "simple-article"
      "crossmark" => 1
      "licencia" => "http://creativecommons.org/licenses/by/4.0/"
      "subdocumento" => "crp"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:1 [
        "total" => 0
      ]
      "pt" => array:12 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Dermatologia Tropical&#47;Infectoparasit&#225;ria</span>"
        "titulo" => "S&#237;filis maligna em paciente com infe&#231;&#227;o pelo v&#237;rus da imunodefici&#234;ncia adquirida &#40;HIV&#41;"
        "tienePdf" => "pt"
        "tieneTextoCompleto" => "pt"
        "tieneResumen" => "pt"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "641"
            "paginaFinal" => "643"
          ]
        ]
        "contieneResumen" => array:1 [
          "pt" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "pt" => true
        ]
        "contienePdf" => array:1 [
          "pt" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0010"
            "etiqueta" => "Figura 2"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr2.jpeg"
                "Alto" => 1133
                "Ancho" => 1508
                "Tamanyo" => 237720
              ]
            ]
            "descripcion" => array:1 [
              "pt" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Exame imuno&#8208;histoqu&#237;mico positivo para <span class="elsevierStyleItalic">Treponema pallidum</span> &#40;630&#215;&#41;&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Ana Sofia Pereira, Aluixa Lozada, Ana Filipe Monteiro"
            "autores" => array:3 [
              0 => array:2 [
                "nombre" => "Ana Sofia"
                "apellidos" => "Pereira"
              ]
              1 => array:2 [
                "nombre" => "Aluixa"
                "apellidos" => "Lozada"
              ]
              2 => array:2 [
                "nombre" => "Ana Filipe"
                "apellidos" => "Monteiro"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "pt"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S0365059622001295"
          "doi" => "10.1016/j.abd.2021.11.003"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059622001295?idApp=UINPBA00008Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275222001564?idApp=UINPBA00008Z"
      "url" => "/26662752/0000009700000005/v1_202209080628/S2666275222001564/v1_202209080628/pt/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S0365059622001313"
    "issn" => "03650596"
    "doi" => "10.1016/j.abd.2021.05.021"
    "estado" => "S300"
    "fechaPublicacion" => "2022-09-01"
    "aid" => "593"
    "copyright" => "Sociedade Brasileira de Dermatologia"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by/4.0/"
    "subdocumento" => "crp"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Images in Dermatology</span>"
      "titulo" => "Darier disease&#58; the use of dermoscopy in monitoring acitretin treatment"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "644"
          "paginaFinal" => "647"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0015"
          "etiqueta" => "Figure 3"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 1041
              "Ancho" => 3175
              "Tamanyo" => 450634
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0015"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dermatoscopic examination &#40;&#215;10&#41;&#46; &#40;A&#41;&#44; Before acitretin treatment&#46; Big comedo-like openings &#40;300 to 500 microns&#41; with a central hyperkeratotic structure&#44; surrounded by a whitish scaling halo&#46; &#40;B&#41;&#44; After acitretin treatment&#46; Few white shiny clods with a pinkish homogeneous background&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Catalina Silva-Hirschberg, Ra&#250;l Cabrera, Mar&#237;a Paz Roll&#225;n, Alex Castro"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Catalina"
              "apellidos" => "Silva-Hirschberg"
            ]
            1 => array:2 [
              "nombre" => "Ra&#250;l"
              "apellidos" => "Cabrera"
            ]
            2 => array:2 [
              "nombre" => "Mar&#237;a Paz"
              "apellidos" => "Roll&#225;n"
            ]
            3 => array:2 [
              "nombre" => "Alex"
              "apellidos" => "Castro"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "pt" => array:9 [
        "pii" => "S2666275222001588"
        "doi" => "10.1016/j.abdp.2021.05.004"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "pt"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275222001588?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059622001313?idApp=UINPBA00008Z"
    "url" => "/03650596/0000009700000005/v1_202208290604/S0365059622001313/v1_202208290604/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S0365059622001167"
    "issn" => "03650596"
    "doi" => "10.1016/j.abd.2021.10.005"
    "estado" => "S300"
    "fechaPublicacion" => "2022-09-01"
    "aid" => "578"
    "documento" => "article"
    "crossmark" => 1
    "licencia" => "http://creativecommons.org/licenses/by/4.0/"
    "subdocumento" => "crp"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:12 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Tropical&#47;Infectoparasitary Dermatology</span>"
      "titulo" => "Kerion celsi caused by <span class="elsevierStyleItalic">Trichophyton tonsurans</span> in an adult"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "637"
          "paginaFinal" => "640"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0015"
          "etiqueta" => "Figure 3"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 1086
              "Ancho" => 2508
              "Tamanyo" => 234879
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0100"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Trichophyton tonsurans&#46;</span> &#40;A&#41;&#44; Microbiological culture&#46; &#40;B&#41;&#44; Thin and septate hyphae with chlamydoconidia and multiple conidia arranged in alternate ways and mirrored&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Jacqueline Paulina Aguirre Sotelo, V&#237;ctor Manuel Tarango Martinez, Lucio Vera Cabrera"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Jacqueline Paulina"
              "apellidos" => "Aguirre Sotelo"
            ]
            1 => array:2 [
              "nombre" => "V&#237;ctor Manuel"
              "apellidos" => "Tarango Martinez"
            ]
            2 => array:2 [
              "nombre" => "Lucio"
              "apellidos" => "Vera Cabrera"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "pt" => array:9 [
        "pii" => "S266627522200145X"
        "doi" => "10.1016/j.abdp.2022.07.008"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "pt"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S266627522200145X?idApp=UINPBA00008Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059622001167?idApp=UINPBA00008Z"
    "url" => "/03650596/0000009700000005/v1_202208290604/S0365059622001167/v1_202208290604/en/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Tropical&#47;Infectoparasitary Dermatology</span>"
    "titulo" => "Malignant syphilis in a patient with acquired human immunodeficiency virus &#40;HIV&#41; infection"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "641"
        "paginaFinal" => "643"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Ana Sofia Pereira, Aluixa Lozada, Ana Filipe Monteiro"
        "autores" => array:3 [
          0 => array:4 [
            "nombre" => "Ana Sofia"
            "apellidos" => "Pereira"
            "email" => array:1 [
              0 => "sfigpereira@gmail.com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Aluixa"
            "apellidos" => "Lozada"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Ana Filipe"
            "apellidos" => "Monteiro"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Dermatovenereology Service&#44; Hospital de Santar&#233;m&#44; Santar&#233;m&#44; Portugal"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Anatomopathological Service&#44; Hospital de Santar&#233;m&#44; Santar&#233;m&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Dermatovenereology Service&#44; Hospital Garcia de Orta&#44; Almada&#44; Portugal"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1334
            "Ancho" => 3175
            "Tamanyo" => 316473
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical aspect of the lesions &#40;A&#41; initial erythematous-squamous papules&#44; &#40;B&#41; ulcerated plaques on the trunk &#40;C&#41; lesions covered with rupioid crusts at higher magnification&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 57-year-old human immunodeficiency virus &#40;HIV&#41; positive patient came to the Department of Dermatology due to a symmetrical and generalized dermatosis consisting of erythematous-squamous papules with one-month evolution &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; which gradually progressed to painful ulcerated plaques and nodules&#44; some covered with lamellar and adherent crusts &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#8210;C&#41;&#46; The lesions were found on the scalp&#44; face&#44; trunk and also on the limbs&#46; The palms&#44; soles and mucous membranes were spared&#46; The patient also reported fever&#44; night sweats&#44; and non-quantified weight loss in the previous weeks&#46; He denied having risky sexual behaviors and declared having had a single sexual partner in the last 10 years&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination revealed bilateral inguinal adenomegaly&#44; with no genital or perineal lesions&#46; The neurological examination was normal&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The laboratory tests revealed a viral load of &#60;20 copies&#47;&#956;L and a CD4&#43; cell count of 507 &#956;L&#46; The VDRL &#40;Venereal Disease Research Laboratory&#41; test was positive at 1&#58;32 dilutions&#44; as was the RPR &#40;Rapid Plasma Reagin&#41;&#44; at a titer of 1&#58;128&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A skin biopsy was performed&#44; which revealed a lymphohistiocytic infiltrate in the superficial dermis&#44; and no plasma cells or eosinophils were observed&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Immunohistochemistry for spirochetes showed the presence of numerous &#8216;corkscrew-shaped&#8217; microorganisms&#44; compatible with <span class="elsevierStyleItalic">Treponema pallidum</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis of malignant syphilis was established and an intramuscular injection of benzathine penicillin G 2&#46;4 MU was administered once a week&#44; for three weeks&#46; There was no Jarisch-Herxheimer &#40;JH&#41; reaction&#46; The skin lesions gradually resolved&#44; with residual hypopigmented scars&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Malignant syphilis &#40;MS&#41;&#44; also known as lues maligna or rupioid syphilis&#44; is an uncommon form of secondary syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Co-infection with HIV seems to be an important predisposing factor for MS&#44; as these patients are 60-fold more likely to have this form of syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Low CD4 counts may also favor MS&#44; as most patients with HIV and MS have CD4 counts &#60;500 cells&#47;&#956;L&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; there have been reported cases of MS in immunocompetent individuals&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> as well as in HIV-positive individuals with normal CD4 counts&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> as the patient described in the present case&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The classic clinical presentation of MS consists of squamous or crusted papules and plaques that become ulcerated or necrotic&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Due to the nonspecificity of the lesions&#44; the differential diagnosis must include several entities&#44; such as pyoderma gangrenosum&#44; vasculitis&#44; lymphoma&#44; pityriasis lichenoides&#44; erythema necrotisans and ecthyma gangrenosum&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The criteria developed in 1969 and used to the present day to aid in the diagnosis of MS include &#40;1&#41; Compatible clinical and microscopic aspects&#59; &#40;2&#41; High serological titer for syphilis&#59; &#40;3&#41; Severe JH reaction&#59; and &#40;4&#41; Excellent response to antibiotic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In the present case&#44; the diagnosis of MS was confirmed by the suggestive clinical condition&#44; the positive VDRL and RPR tests&#44; and the rapid resolution with the administration of penicillin&#46; Additionally&#44; the identification of <span class="elsevierStyleItalic">Treponema pallidum</span> by immunohistochemistry was crucial&#44; given the nonspecificity of the histological findings&#44; namely the absence of plasma cells&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although uncommon&#44; MS is a clinical entity that should be promptly recognized by dermatologists and general practitioners&#44; as its early diagnosis and treatment result in less morbidity and better control of the dissemination of the infection&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0070" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#39; contributions</span><p id="par0075" class="elsevierStylePara elsevierViewall">Ana Sofia Pereira&#58; Drafting and editing of the manuscript&#59; literature search&#59; approval of the final version of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Aluixa Lozada&#58; Analysis and interpretation of data&#59; approval of the final version of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Ana Filipe Monteiro&#58; Critical review of the content&#59; approval of the final version of the manuscript&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:6 [
        0 => array:3 [
          "identificador" => "xres1763872"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1551041"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Financial support"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Authors&#39; contributions"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Conflicts of interest"
        ]
        5 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2021-09-07"
    "fechaAceptado" => "2021-11-10"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1551041"
          "palabras" => array:3 [
            0 => "HIV"
            1 => "Syphilis"
            2 => "<span class="elsevierStyleItalic">Treponema pallidum</span>"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Malignant syphilis is an uncommon variant of syphilis&#44; most often &#40;but not always&#41; found in immunosuppressed individuals&#46; This report describes the case of a 57-year-old man&#44; infected with the acquired human immunodeficiency virus &#40;HIV&#41;&#44; with a generalized picture of erythematous-squamous papules that rapidly progressed to painful and ulcerated plaques and nodules&#44; some covered with a black rupioid crust&#46; The analytical study performed revealed positive VDRL &#40;Venereal Disease Research Laboratory&#41; and RPR &#40;Rapid Plasma Reagin&#41;&#46; The skin biopsy was nonspecific&#59; however&#44; the immunohistochemical analysis disclosed the presence of spirochetes&#46; The patient was then treated with benzathine penicillin G 2&#46;4 MU once a week IM for three weeks&#44; with progressive resolution of the lesions&#46; Considering its rarity&#44; this atypical form of syphilis that needs to be known to better recognize its clinical presentation and provide more prompt treatment to patients&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Hospital de Santar&#233;m&#44; Santar&#233;m&#44; Portugal&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1334
            "Ancho" => 3175
            "Tamanyo" => 316473
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical aspect of the lesions &#40;A&#41; initial erythematous-squamous papules&#44; &#40;B&#41; ulcerated plaques on the trunk &#40;C&#41; lesions covered with rupioid crusts at higher magnification&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1133
            "Ancho" => 1508
            "Tamanyo" => 237161
          ]
        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Immunohistochemical examination positive for <span class="elsevierStyleItalic">Treponema pallidum</span> &#40;&#215;630&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:5 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "S&#237;filis maligna&#58; revisi&#243;n sistem&#225;tica de los casos publicados entre los anos 2014&#8211;2018"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "O&#46; Wibisono"
                            1 => "I&#46; Idrus"
                            2 => "K&#46; Djawad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Actas Dermosifiliogr &#40;Engl Ed&#41;"
                        "fecha" => "2021"
                        "paginaInicial" => "S0001"
                        "paginaFinal" => "7310"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Active syphilis in HIV infection&#58; a multicentre retrospective survey&#46; The German AIDS Study Group &#40;GASG&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46; Sch&#246;fer"
                            1 => "M&#46; Imhof"
                            2 => "E&#46; Thoma-Greber"
                            3 => "N&#46;H&#46; Brockmeyer"
                            4 => "M&#46; Hartmann"
                            5 => "G&#46; Gerken"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/sti.72.3.176"
                      "Revista" => array:6 [
                        "tituloSerie" => "Genitourin Med"
                        "fecha" => "1996"
                        "volumen" => "72"
                        "paginaInicial" => "176"
                        "paginaFinal" => "181"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8707318"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Malignant syphilis in an immunocompetent female patient"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;B&#46; Requena"
                            1 => "C&#46;R&#46; Orasmo"
                            2 => "J&#46;P&#46; Ocanha"
                            3 => "S&#46;R&#46; Barraviera"
                            4 => "M&#46;E&#46; Marques"
                            5 => "S&#46;A&#46; Marques"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1590/abd1806-4841.20143155"
                      "Revista" => array:6 [
                        "tituloSerie" => "An Bras Dermatol"
                        "fecha" => "2014"
                        "volumen" => "89"
                        "paginaInicial" => "970"
                        "paginaFinal" => "972"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25387504"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lues Maligna"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;A&#46; Johnson"
                            1 => "A&#46;M&#46; Spivak"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Open Forum Infect Dis"
                        "fecha" => "2017"
                        "volumen" => "4"
                        "paginaInicial" => "ofx139"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lues maligna&#58; Presentation of a case and a review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46;A&#46; Fisher"
                            1 => "L&#46;W&#46; Chang"
                            2 => "D&#46;L&#46; Tuffanelli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.99.1.70"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "1969"
                        "volumen" => "99"
                        "paginaInicial" => "70"
                        "paginaFinal" => "73"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/5761808"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/03650596/0000009700000005/v1_202208290604/S0365059622001295/v1_202208290604/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "80635"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Tropical&#47;Infectoparasitary Dermatology"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/03650596/0000009700000005/v1_202208290604/S0365059622001295/v1_202208290604/en/main.pdf?idApp=UINPBA00008Z&text.app=https://clinics.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059622001295?idApp=UINPBA00008Z"
]
Compartilhar
Informação da revista
Vol. 97. Núm. 5.
Páginas 641-643 (1 setembro 2022)
Compartilhar
Compartilhar
Baixar PDF
Mais opções do artigo
Visitas
6099
Vol. 97. Núm. 5.
Páginas 641-643 (1 setembro 2022)
Tropical/Infectoparasitary Dermatology
Open Access
Malignant syphilis in a patient with acquired human immunodeficiency virus (HIV) infection
Visitas
6099
Ana Sofia Pereiraa,
Autor para correspondência
sfigpereira@gmail.com

Corresponding author.
, Aluixa Lozadab, Ana Filipe Monteiroc
a Dermatovenereology Service, Hospital de Santarém, Santarém, Portugal
b Anatomopathological Service, Hospital de Santarém, Santarém, Portugal
c Dermatovenereology Service, Hospital Garcia de Orta, Almada, Portugal
Este item recebeu

Under a Creative Commons license
Informação do artigo
Resume
Texto Completo
Bibliografia
Baixar PDF
Estatísticas
Figuras (2)
Abstract

Malignant syphilis is an uncommon variant of syphilis, most often (but not always) found in immunosuppressed individuals. This report describes the case of a 57-year-old man, infected with the acquired human immunodeficiency virus (HIV), with a generalized picture of erythematous-squamous papules that rapidly progressed to painful and ulcerated plaques and nodules, some covered with a black rupioid crust. The analytical study performed revealed positive VDRL (Venereal Disease Research Laboratory) and RPR (Rapid Plasma Reagin). The skin biopsy was nonspecific; however, the immunohistochemical analysis disclosed the presence of spirochetes. The patient was then treated with benzathine penicillin G 2.4 MU once a week IM for three weeks, with progressive resolution of the lesions. Considering its rarity, this atypical form of syphilis that needs to be known to better recognize its clinical presentation and provide more prompt treatment to patients.

Keywords:
HIV
Syphilis
Treponema pallidum
Texto Completo

A 57-year-old human immunodeficiency virus (HIV) positive patient came to the Department of Dermatology due to a symmetrical and generalized dermatosis consisting of erythematous-squamous papules with one-month evolution (Fig. 1A), which gradually progressed to painful ulcerated plaques and nodules, some covered with lamellar and adherent crusts (Fig. 1B‒C). The lesions were found on the scalp, face, trunk and also on the limbs. The palms, soles and mucous membranes were spared. The patient also reported fever, night sweats, and non-quantified weight loss in the previous weeks. He denied having risky sexual behaviors and declared having had a single sexual partner in the last 10 years.

Figure 1.

Clinical aspect of the lesions (A) initial erythematous-squamous papules, (B) ulcerated plaques on the trunk (C) lesions covered with rupioid crusts at higher magnification.

(0.3MB).

The physical examination revealed bilateral inguinal adenomegaly, with no genital or perineal lesions. The neurological examination was normal.

The laboratory tests revealed a viral load of <20 copies/μL and a CD4+ cell count of 507 μL. The VDRL (Venereal Disease Research Laboratory) test was positive at 1:32 dilutions, as was the RPR (Rapid Plasma Reagin), at a titer of 1:128.

A skin biopsy was performed, which revealed a lymphohistiocytic infiltrate in the superficial dermis, and no plasma cells or eosinophils were observed.

Immunohistochemistry for spirochetes showed the presence of numerous ‘corkscrew-shaped’ microorganisms, compatible with Treponema pallidum (Fig. 2).

Figure 2.

Immunohistochemical examination positive for Treponema pallidum (×630).

(0.23MB).

The diagnosis of malignant syphilis was established and an intramuscular injection of benzathine penicillin G 2.4 MU was administered once a week, for three weeks. There was no Jarisch-Herxheimer (JH) reaction. The skin lesions gradually resolved, with residual hypopigmented scars.

Malignant syphilis (MS), also known as lues maligna or rupioid syphilis, is an uncommon form of secondary syphilis.1 Co-infection with HIV seems to be an important predisposing factor for MS, as these patients are 60-fold more likely to have this form of syphilis.2

Low CD4 counts may also favor MS, as most patients with HIV and MS have CD4 counts <500 cells/μL.1 However, there have been reported cases of MS in immunocompetent individuals,3 as well as in HIV-positive individuals with normal CD4 counts,4 as the patient described in the present case.

The classic clinical presentation of MS consists of squamous or crusted papules and plaques that become ulcerated or necrotic.1

Due to the nonspecificity of the lesions, the differential diagnosis must include several entities, such as pyoderma gangrenosum, vasculitis, lymphoma, pityriasis lichenoides, erythema necrotisans and ecthyma gangrenosum.

The criteria developed in 1969 and used to the present day to aid in the diagnosis of MS include (1) Compatible clinical and microscopic aspects; (2) High serological titer for syphilis; (3) Severe JH reaction; and (4) Excellent response to antibiotic therapy.5

In the present case, the diagnosis of MS was confirmed by the suggestive clinical condition, the positive VDRL and RPR tests, and the rapid resolution with the administration of penicillin. Additionally, the identification of Treponema pallidum by immunohistochemistry was crucial, given the nonspecificity of the histological findings, namely the absence of plasma cells.

Although uncommon, MS is a clinical entity that should be promptly recognized by dermatologists and general practitioners, as its early diagnosis and treatment result in less morbidity and better control of the dissemination of the infection.

Financial support

None declared.

Authors' contributions

Ana Sofia Pereira: Drafting and editing of the manuscript; literature search; approval of the final version of the manuscript.

Aluixa Lozada: Analysis and interpretation of data; approval of the final version of the manuscript.

Ana Filipe Monteiro: Critical review of the content; approval of the final version of the manuscript.

Conflicts of interest

None declared.

References
[1]
O. Wibisono, I. Idrus, K. Djawad.
Sífilis maligna: revisión sistemática de los casos publicados entre los anos 2014–2018.
Actas Dermosifiliogr (Engl Ed), (2021), pp. S0001-7310
[2]
H. Schöfer, M. Imhof, E. Thoma-Greber, N.H. Brockmeyer, M. Hartmann, G. Gerken, et al.
Active syphilis in HIV infection: a multicentre retrospective survey. The German AIDS Study Group (GASG).
Genitourin Med, 72 (1996), pp. 176-181
[3]
C.B. Requena, C.R. Orasmo, J.P. Ocanha, S.R. Barraviera, M.E. Marques, S.A. Marques.
Malignant syphilis in an immunocompetent female patient.
An Bras Dermatol, 89 (2014), pp. 970-972
[4]
R.A. Johnson, A.M. Spivak.
Lues Maligna.
Open Forum Infect Dis, 4 (2017), pp. ofx139
[5]
D.A. Fisher, L.W. Chang, D.L. Tuffanelli.
Lues maligna: Presentation of a case and a review of the literature.
Arch Dermatol, 99 (1969), pp. 70-73

Study conducted at the Hospital de Santarém, Santarém, Portugal.

Copyright © 2022. Sociedade Brasileira de Dermatologia
Baixar PDF
Idiomas
Anais Brasileiros de Dermatologia (Portuguese)
Opções de artigo
Ferramentas
en pt
Cookies policy Política de cookies
To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here. Utilizamos cookies próprios e de terceiros para melhorar nossos serviços e mostrar publicidade relacionada às suas preferências, analisando seus hábitos de navegação. Se continuar a navegar, consideramos que aceita o seu uso. Você pode alterar a configuração ou obter mais informações aqui.