Image Gallery: A case of malignant syphilis in an HIV‐infected patient mimicking fungal infection

Hand eczema is one of the most common skin diseases with some studies estimating that up to 10% of the European population has some degree of hand eczema at any one time. There are various causes with some people having a genetic tendency and others developing hand eczema due to their jobs, often a result of hand washing in healthcare or hospitality sectors. The initial treatment of hand eczema is to avoid obvious triggers and use plenty of moisturising creams. If problems continue steroid creams are prescribed. These measures are often enough but if the eczema continues patients are then offered either ultraviolet (UV) light based treatments or tablets. This research study investigated two different forms of UV light treatment which are used to treat eczema. PUVA involves soaking the hands in a water‐based solution of a photosensitising drug before receiving UVA light for 5‐15 minutes whereas NBUVB involves a 1‐2 minute exposure to UVB light. PUVA is the traditional treatment and has been used for 30 years. It is time consuming. There are some concerns that excessive PUVA use could increase the risk of skin cancers and indefinite repeated treatment is not used. The research study invited patients with hand eczema not improving with steroid creams to receive either PUVA or UVB treatment. The severity of their eczema was scored before, during and after treatment. Due to difficulties in recruiting enough patients it was not possible to say which treatment was better. However, the study did show that both treatments improved the eczema severity. There were more side effects with the NBUVB treatment mainly due to mild episodes of skin redness. This research has provided new information. We now know that NBUVB is a safe and acceptable treatment for hand eczema. It does lead to improvement in hand eczema severity. It takes less time but does produce more side effects than PUVA. We have measured the improvement in patients’ eczema with both treatments using official scoring systems which means we are now in a position to design a larger clinical trial to determine which treatment is more effective.     

儿童获得性梅毒14例分析

目的 分析儿童获得性梅毒的临床表现及其治疗方法。方法 回顾分析2007年7月至2010年12月诊治的14例儿童获得性梅毒患者的临床资料。结果 14例患者中10例为二期梅毒,早、晚期潜伏梅毒各2例。14例患者均有与现症梅毒患者密切接触史或被成人梅毒患者口内咀嚼食物后喂养史。所有患者血清快速血浆反应素环状卡片试验（RPR）及梅毒螺旋体血凝试验（TPHA）均阳性。其皮损主要发生于口腔黏膜,躯干少见,表现为黏膜白斑和黏膜湿丘疹、皮肤脓疱等。7例患者被误诊为其他皮肤病。结论 儿童获得性梅毒临床常被误诊或忽视。有不典型皮疹、尤其是与活动性梅毒患者有密切接触者,应考虑儿童获得梅毒可能。     

Bone invasion in secondary syphilis: case reports.

The affinity of treponemes for bone tissue is well known, but the incidence of bone infection in the early stages of syphilis is uncertain. Although case reports of early bone invasion are few, reviews of large numbers of patients with early syphilis indicate that the incidence is probably greater than at present believed. Two case reports are presented.     

Penile and scrotal lesions in leprosy: case reports

Six leprosy patients in the Ridley-Jopling spectrum of BT-BL showing lesions on penis and scrotum are presented, as we believe that this common enough clinical feature is not well documented in the literature.     

Mucocutaneous manifestations of HIV‐infected patients in the era of HAART in Guangxi Zhuang Autonomous Region,China

Background Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are frequently associated with diverse mucocutaneous manifestations. However, few studies of HIV/AIDS‐related mucocutaneous manifestations have been reported in China. Objective To investigate the occurrence of mucocutaneous disorders and their relationship with the degree of immunosuppression in 348 HIV‐infected Chinese patients. The influence of highly active antiretroviral therapy (HAART) on the spectrum of mucocutaneous manifestations was also evaluated. Methods A cross‐sectional study was performed on 348 HIV‐infected Chinese patients seen at the Guangxi Longtan Hospital from August 2010 to November 2010. Collected information included demographic data, HIV‐associated mucocutaneous disorders, CD4 cell count, AIDS‐defining illness and antiretroviral therapy. Results In this study, 62.9% of all patients had mucocutaneous disorders. The prevalence of mucocutaneous disorders in the patients who had received HAART was lower than in those without HAART (54.05% vs. 88.76%, P < 0.001). The prevalence of mucocutaneous disorders was higher in the patients with CD4 < 200 cells/mm³ in comparison to those with CD4 ≥ 200 cells/mm³ (P < 0.05). The most common mucocutaneous disorders were oral candidiasis (28.47%), Penicillium marneffei infection (11.49%), drug eruptions (10.06%) and pruritic papular eruption (PPE 5.75%). Oral candidiasis, P. marneffei infection and PPE were significantly more prevalent in patients with a CD4 cell count below 200 cells/mm³, but frequency of drug eruptions was not related to the level of CD4 cell counts. Patients treated with HAART had decreased rates of herpes simplex, oral candidiasis and P. marneffei infection, but increased rates of drug eruptions. Conclusions A wide range of mucocutaneous disorders were observed in HIV‐infected Chinese patients. Oral candidiasis, P. marneffei infection and PPE may be the signs of advanced HIV infection. HAART had an impact on the spectrum of HIV‐associated mucocutaneous disorders.     

Leprosy: two case reports from Dresden, Germany

Leprosy is very rare in Germany. In 2003, only three cases were reported. In the Department of Dermatology, Dresden-Friedrichstadt, two cases from Asia had been diagnosed during the last 5 years, a paucibacillary tuberculoid leprosy and a multibacillary lepromatous leprosy. In both, there was a diagnostic delay of several months (3–7 months). The need for early detection of this mycobacteriosis also in nonepidemic areas of the world and the importance of a correct diagnosis by the dermatologist is hereby emphasized.     

Keratosis spinulosa developing in borderline-tuberculoid lesions during type I lepra reaction: two case reports

Two cases of borderline-tuberculoid leprosy which developed keratosis spinulosa over the anaesthetic areas alone during type I lepra reactions are described. Both patients only developed spiny papules during the period of reaction and subsided with control of the reaction. The probable mechanism of this peculiar phenomenon might be due to the generation of epidermal growth factors by local T cell activation during the type I lepra reaction.     

Tertiary syphilis and Kaposi sarcoma mistaken for systemic sarcoidosis in an HIV‐negative patient

We describe a case of an HIV‐negative man who was mistakenly diagnosed as having systemic sarcoidosis, which led to a delay in diagnosing tertiary syphilis and Kaposi sarcoma (KS). The patient presented initially with scrotal swelling and leg oedema. Initial blood tests were unremarkable and HIV testing was negative. The patient then developed unilateral limb weakness. Computed tomography showed lung lesions and hilar lymphadenopathy, while magnetic resonance imaging showed an increased signal in the cervical cord. Serum angiotensin‐converting enzyme was raised, and a diagnosis of sarcoidosis was made and the patient started on steroids. Subsequently, his clinical symptoms and radiological abnormalities improved. However, he then developed progressive neurological deficits over several weeks, together with uveitis and cutaneous lesions. A uveitis screen showed a raised venereal disease research laboratory test titre and the cause of his multisystemic symptoms was revisited. He was diagnosed with tertiary syphilis and treated with antibiotics. Dermatologists reviewed the skin lesions and diagnosed KS, which was confirmed with biopsies. The patient's neurological deficit remains. Syphilis should be considered in the differential diagnosis of any patient presenting with neurological problems, skin lesions or symptoms affecting multiple systems. Co‐existing KS presented an extra therapeutic challenge in this case.     

Skin diseases and sexually transmitted diseases in HIV‐infected patients on HAART compared to a non‐infected population – results of a retrospective study

Background: The prevalence of skin diseases and sexually transmitted diseases has always played a special role in studying HIV infections, both because of immunosuppression and simultaneous transmission. In the early years of the HIV epidemic, skin diseases were often a pathognomonic sign in heavily immunosuppressed patients. With highly active antiretroviral therapy (HAART), HIV infection has become a treatable chronic disease. For this reason the spectrum as well as the prevalence of skin diseases has changed. Pathognomonic skin diseases have become rare and the wide spectrum today ranges from infectious to iatrogenic skin diseases. Patients and methods: From April to October 2007 166 HIV‐infected patients and 173 patients of a comparison group were surveyed in retrospect by means of a questionnaire about skin diseases and sexually transmitted diseases that appeared over the entire year 2006. Results and conclusions: The study confirmed the shift to a wide variety of mostly trivial skin diseases and away from severe opportunistic skin diseases. HIV‐infected patients today have more numerous skin problems than the non‐infected population and thus need regular dermatologic control examinations.     

HIV‐associated psoriasis: Epidemiology,pathogenesis, and management

People living with HIV (PLWH) are affected by a higher incidence skin disorders, which are often associated with high morbidity and mortality. In particular, psoriasis affects PLWH severely and for a longer time than the general population. Human immunodeficiency virus (HIV) infection is characterized by a progressive decrease in CD4⁺ T‐cell count, and it could seem paradoxical that psoriasis exacerbations are more frequent in this subset of patients than the general population, even though it is commonly observed at any stage of infection. For a long time, there have been limited therapeutic choices for PLWH affected by psoriasis. The introduction of the combined antiretroviral therapy dramatically changed the natural course of both HIV and psoriasis in PLWH, leading to an improvement of quality and duration of life. However, the clinical severity of psoriasis in PLWH often requires the use of immunosuppressant drugs. Knowledge about their safety and efficacy are limited to case‐reports, small case‐series and studies, therefore their use has not yet entered the routine. Further studies are needed to determine if immunosuppressive drugs can be safely and effectively used in PLWH affected by psoriasis and other autoimmune disorders.     

Gummatous lesions in men infected with human immunodeficiency virus and syphilis.

Two HIV-infected men are reported who developed gummatous lesions more than 12 months after appropriate treatment of presumptive syphilis. In one patient the lesions developed without any change in the VDRL titre. The most likely explanation for these lesions is reactivation of syphilis in the context of HIV infection. As these lesions respond to penicillin, the possible reactivation of appropriately treated syphilis, or even yaws, should now be considered in any ulcerative lesion in HIV infected individuals at risk from treponemal infection.     

Cutaneous manifestations in patients with microscopic polyangiitis: two case reports and a minireview

Microscopic polyangiitis is a systemic small vessel vasculitis, which often has cutaneous and musculoskeletal features. Microscopic polyangiitis is a member of the family of anti-neutrophil cytoplasmic auto-antibody (ANCA)-associated vasculitides and is strongly associated with anti-myeloperoxidase (MPO)-ANCA. Titres of MPO-ANCA may reflect disease activity and play a pathogenic role. Patients with microscopic polyangiitis usually present with erythematous macules on the extremities as the first cutaneous manifestation. Skin biopsy specimens from the erythema reveal small-sized vessels that are infiltrated with neutrophils, consistent with leukocytoclastic vasculitis, in the deep dermis to the subcutaneous fat tissue. The cutaneous involvement is present at an early stage of microscopic polyangiitis with other non-specific symptoms, such as arthralgias and myalgias. The initial cutaneous manifestations are important in early diagnosis of possible ANCA-associated vasculitides with elevated ANCA titres.