A nodular-ulcerative form of secondary syphilis in AIDS

An uncommon variant in the pre-AIDS era, lues maligna is a nodular-ulcerative form of secondary syphilis. We present a case of a 41-year-old man with HIV infection who developed fever, chills, nausea, vomiting, right upper quadrant abdominal pain, weight loss, watery diarrhea, and a painless, nonpruritic rash. He had diffuse nodular-ulcerative lesions in various stages of development. He was found to have a CD4 count of 101 cells/mm³ (22%), an HIV viral load of 2,735,060 copies/mL, and a positive rapid plasma reagin at 1:64. He was started on emtricitabine, tenofovir, and dolutegravir, as well as doxycycline. He was given benzathine penicillin 2.4 million units intramuscularly and within hours developed a Jarisch-Herxheimer reaction. Skin lesions showed signs of healing, and constitutional symptoms improved 48 hours later.