Papulonecrotic tuberculid mimicking lues maligna in an immunocompromised male

Papulonecrotic tuberculid (PNT) is a rare hypersensitivity reaction to Mycobacterium tuberculosis, typically seen in immunocompetent individuals but occasionally reported in human immunodeficiency virus (HIV)-positive patients. We describe the case of a 30-year-old HIV-positive male with high-risk sexual behavior presenting with crusted papulopustular lesions and severe headache. Cerebrospinal fluid and venereal disease research laboratory (VDRL) were positive for VDRL and treponema pallidum hemagglutination confirming neurosyphilis, while skin biopsy revealed PNT. This case underscores the diagnostic challenge of differentiating co-infections and id reactions in HIV. The patient improved significantly with anti-tubercular therapy and benzylpenicillin.