Male patient, 40 years old, Han Chinese.
Complaint: rash for 45 days, aggravated with fever for 25 days.
History: The patient had a history of homosexuality for more than 10 years. 45 days ago, he developed scattered red papules on the skin of the lower extremities with mild itching without any obvious cause, spreading upward to the trunk, upper extremities, neck and face, and lost 5 kg in weight. 25 days ago, the patient developed a fever with no obvious cause, with body temperature fluctuating between 37 and 38 degrees, occasionally reaching 39 and 40 degrees, with an aggravated rash, accompanied by false sweating, no night sweats, cough and other discomfort. The result was positive, syphilis RPR (+), ultrasound suggested that both axillary and inguinal lymph nodes were enlarged, perfect rash biopsy, the result was not returned, CD4+T was 18.5%, for further treatment came to our hospital.
On examination: T36.5℃, P80 times/min, R20 times/min, BP120/70mmHg. There was no yellow staining of the sclera, a 7-8 mm diameter swelling with congestion and edema was seen under the left conjunctiva, the left lid conjunctiva was congested, the right conjunctiva was not abnormal, the cornea was transparent and without scarring, the corneal reflex was sensitive, the bilateral pupils were equal in size and round, the bilateral pupils had a sensitive reflex to light, no white spots were seen in the oral mucosa, the neck was soft and nonresistant, the respiratory sounds of both lungs were clear, no dry or wet 80 beats/min was heard, the heart rhythm was flush, and no sounds were heard in each valve auscultation area No pathological murmur, flat abdomen, no pressure pain and rebound pain throughout the abdomen, no masses palpable in the abdomen, no liver, spleen or gallbladder palpable, negative Murphy’s sign, normal physiological reflexes, pathological signs (-), meningeal stimulation signs (-).
Past history: history of hypertension, coronary heart disease, diabetes mellitus, other infectious diseases, food and drug allergy, and surgical trauma were denied.
Family and personal history: nothing specific.
Preliminary analysis.
1, AIDS: the patient is a middle-aged male, history of homosexuality for more than 10 years, the three hospitals in North Medicine to check anti-HIV (+), Beijing Haidian District CDC confirmation test positive, the diagnosis of HIV infection is established, the patient 45 days ago, scattered red papules around the body, outside the hospital CD4 + T is 18.5%, consider the patient into the AIDS stage, so the diagnosis of AIDS is established.
2, the cause of the rash to be investigated, conjunctival occupation cause to be investigated: the patient 45 days ago appeared scattered red maculopapular rash around the body, the back part of the fusion into a patch, the left eye conjunctiva also appeared 7-8 mm in diameter similar to the papule-like swelling, accompanied by congestion, edema, inguinal and axillary lymph nodes enlargement, currently consider the possibility of lymphoma, in the external hospital has been perfected pathological examination, waiting for the results to return.
3. Syphilis: There is a history of homosexuality, and TPHA (+) and RPR (+) were found in the external hospital, so the diagnosis of syphilis was established.
Treatment.
Admission laboratory results: blood routine: leukocytes 2.56×10E9/L, neutrophil percentage 65.98%, neutrophil count 1.69×10E9/L, red blood cell count 3.32×10E12/L, hemoglobin 96.5g/L, platelet count 197×10E9/L. Electrolytes: potassium 4.2mmol/L, sodium 131.3 mmol/L, chloride 96.9mmol/L, urea 2.65mmol/L, creatinine 69umol/L, liver function: alanine aminotransferase 30.4U/L, menthylate aminotransferase 27.3U/L, total bilirubin 8.8umol/L, direct bilirubin 2.8umol/L, albumin 33.2g/L. TB antibody (-); sputum smear (-), sputum antacid stain (-), cryptococcal antigen (-), weakly positive for CMV-IgM; TORCH (-), TPHA (+), RPR1: 32. T lymphocyte subsets: CD45+T 747cells/ul, CD3+ T 582cells/ul, CD3+CD4+ T 94cells/ul, CD3+CD8 +T 472cells/ul, ESR 78mm/h; chest X-ray showed increased texture in both lungs, ultrasound showed thickened liver parenchyma and no abnormality in chest X-ray; no significant abnormality in chest enhancement CT.
Because the patient’s syphilis was diagnosed clearly in the external hospital, and the subconjunctival occupying lesion, to clarify the presence of neurosyphilis or other neurological lesions, the lumbar puncture and various pathogenic tests were completed on the day of admission, and the results indicated that the cerebrospinal fluid pressure was normal, the CSF had 0 white blood cells, normal protein and sugar, and slightly lower chloride levels. -), CMV-IgM (-); EBV-IgM (-), combined with the absence of neurological signs and symptoms in the patient, neurosyphilis and other neurological opportunistic infections were excluded. After completing the lumbar puncture, we started regular anthemorrhagic treatment (4 million units of aqueous penicillin Q4h). After 3 days of treatment with penicillin, we felt that the peripheral papules gradually shrunk, the back part of the crust, the subconjunctival occupancy of the left eye gradually decreased, and the conjunctival congestion completely absorbed. In addition, because the patient’s CD4+T level was less than 100 units/ul and weakly positive for CMV-IgM, he was treated with sodium fosfomate 3 g Q8h anticytomegalovirus on the 3rd day of admission; the patient’s circumscribed papules completely disappeared on the 14th day of the regular anti-syphilis treatment process, leaving skin pigmentation at the original papules; the left conjunctival occupancy lesion almost disappeared, suggesting that the circumscribed rash and bulbar conjunctival occupancy were syphilis rashes (Figs. (Figures 1 and 2).
The pathological return of the patient’s bone marrow and rash at Peking University Third Hospital 14 days after admission suggested marked plasma cell differentiation within the bone marrow cells; the pathology of the skin papule suggested hyperkeratosis of the epidermis with numerous cellular infiltrates and epithelial keratolysis; hyperplastic infiltration of cells within the dermis with medium-sized cells with clear cytoplasm, and also reticulocyte hyperplasia, vascular hyperplasia, and endothelial obesity; and focal cellular infiltration of the deep dermis with plasma cell transformation. Special immunohistochemical examinations suggested that CD3ε: multiple +; CD4: small +; CD8: +; CD68: scattered +; CD20: multiple +; EBER: individual +; EMA: -; CD2: multiple +; CD7: -; CD30: small +; Ki67: 15%; ALK: -; κ: +; λ: +. The results suggest mixed lymphocytic hyperplasia of the skin and an insufficient basis for the diagnosis of lymphoma.
Final diagnosis: AIDS Stage 2 syphilis Cutaneous syphilis rash Conjunctival syphilis rash of the left eye Cytomegalovirusemia Clinical regression: After the patient completed 14 days of aqueous penicillin treatment, he continued with benzathine penicillin 2.4 MIU intramuscular QW for 3 weeks, the patient was fever-free, the rash and ocular occupying lesions disappeared, and he was discharged clinically well after the HAART treatment plan was developed for him.
Discussion.
AIDS can lead to severe immune deficiency in the body and can present with a variety of different opportunistic pathogenic infections and tumors, of which the common tumors are Kapozi’s sarcoma and lymphoma. Kapozi’s sarcoma is characterized by purple or brown macules, papules and nodules, usually without pruritus or pain, on the lower extremities, oral cavity, face and external genitalia, and may be complicated by lymphedema and visceral involvement. The clinical features of lymphoma are unexplained fever, abnormal liver function, bone marrow involvement, pulmonary lesions (including exudates, multinodular infiltrates, masses, and hilar lymph node enlargement), gastrointestinal involvement, and central nervous system involvement. In this case, red papules were seen on the peripheral skin at the time of admission and fused into patches on the back; at the same time, an occupying lesion was seen under the conjunctiva of the left eye, and the first consideration was whether it was Kapozi’s sarcoma or lymphoma. Bone marrow involvement and pathological biopsy of the rash also did not support the diagnosis of Kapozi’s sarcoma and lymphoma.
In patients with untreated syphilis, stage II syphilis usually occurs 6 weeks to 6 months after infection. It is caused by the syphilis spirochetes in the hard chancre of stage I syphilis reaching the lymph nodes through the lymphatic vessels and spreading throughout the body through blood circulation. In the early stage, there may be fever, fatigue, headache, sore throat, muscle pain, joint pain, anorexia and other systemic symptoms. More than half of the patients have generalized lymph node enlargement, and occasionally liver and spleen enlargement. The blood picture may include leukocytosis, anemia and elevated blood sedimentation. About 70% of patients have a skin rash called syphilis rash. Syphilis rash can have many different manifestations in patients with AIDS.
1. Rose rash: This is the initial syphilis rash that appears as a red, brown or pigmented rose rash, mostly starting to occur on the trunk first. Later, it develops on the extremities, palms and soles of the feet.
2, flat eczema, which occurs in the external genital area, around the anus and other skin folds and moist parts of the papule.
3, papillary syphilis rash: this is due to the development of the disease, some spots can thicken into papules. It is a good idea to take a look at the trunk, buttocks, calves, palms, soles and face. It can show maculopapular, papular, papulosquamous, annular, psoriasis-like damage.
4, mucosal plaque: about 30% of patients have oral mucosal damage, called mucosal plaque. The surface of the damage is covered with gray film, containing a large number of syphilis spirochetes.
The patient’s RPR (+) was checked in a foreign hospital, suggesting syphilis. On the third day of treatment, the patient showed gradual atrophy of the circumferential papules, gradual reduction of conjunctival space-occupying lesions, and gradual absorption of conjunctival congestion, so the diagnostic treatment was considered effective.
In patients with AIDS combined with syphilis, the syphilis rash can have various manifestations.