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Unusual manifestations of syphilis with human immunodeficiency virus infection
578
Journal of the American Academy of Dermatology
Correspondence
department. Since the age of 5 he had flat, small plantar and palmar warts 2 to 3 mm in diameter that later extended to the dorsal surfaces of the hands, arms, and forehead. At the age of 20, he was the victim of a severe car accident in which he sustained a subdural hematoma and acute abdominal bleeding. In the course of surgical exploration, a subhepatic hematoma was drained and the patient was subsequently discharged. Later, he complained of headache and dizziness, which proved to be caused by a posterior fossa abscess and meningitis. Abdominal leakage was also detected and was found to originate in an abdominal abscess. Both abscesses were drained and repeated cultures from both sites revealed the presence of Cryptococcus infection. Although amphotericin B in daily doses of 40 mg improved the patient's general condition, the therapy was discontinued because of leucopenia and thrombocytopenia. Upon evaluation of the patient's immune profile, a normal percentage of T and B cells was found. Examination of the T subpopulation revealed a decrease in the number of T4 (helper) cells and a slight decline in the T4 to Ta ratio, which registered 0.6. The T cell response to mitogens, phytohemagglutinin, and concanavalin A, as well as the lymphocyte response to pokeweed mitogen, was slightly lowered.
Comment. Our results confirm the depressed cellmediated immunity observed by Majewski and colleagues in epidermodysplasia verruciformis. Seemingly, in our case of epidermodysplasia verruciformis, the patient's compromised immune system led to the complications encountered, following trauma.
Vera Leibovici, M.D., and Anda Kanner, M.D. Hadassah University Hospital Jerusalem, Israel
Unusual manifestations of syphilis with human immunodeficiency virus infection To the Editor." It is not necessary to be able to culture Treponerna pallidurn in order to make a microbiologic diagnosis of syphilis easily and commonly in a patient with the primary or secondary stage of the disease. Radolf and Kaplan open their report (J AM ACAD DER~thTOL 1988;18:423-7) as follows: "Microbiologic diagnosis of syphilitic infection is rarely accomplished because the etiologic agent, Treponema pallidum, cannot be cultivated in vitro." Anyone inexperienced in the diagnosis of early syphilis is misled by such a statement, because serum obtained from an early syphilitic cutaneous lesion or external genital mucous membrane lesion
(not the oral mucous membrane) will readily show many T. pallidurn spirochetes with their characteristic spiraling motion and stiff flexing attempts. A drop of normal saline onto a freshly denuded but not bleeding lesion is mixed with serous exudate and aspirated into a tuberculin syringe without a needle a regular wet mount using a clean unscratched slide and coverslip. Examination with a dark-field microscope will usually reveal myriad organisms. Thus microbiologic diagnosis of an early syphilitic lesion is accomplished in minutes in offices, laboratories, or clinics with a dark-field microscope. Serum from an oral lesion is useless because of residential oral spirochetes resembling T. pallidurn contaminating mouth lesions. Our board of health has a dark-field microscope.
William E. McDaniel, M.D. 342 Waller Ave., Lexington, K Y 40504
Reply To the Editor: Dr. McDaniel raises an important point in his comments on the opening sentence for our recent case report. His description of the appropriate technique for obtaining specimens for dark-field microscopy also is appreciated. However, a positive dark-field examination should not be equated with microbiologic confirmation; specimens containing both pathogenic and nonpathogenic treponemes (and even other spirochetes) can give positive dark-field examinations. Confirmation that the Organism visualized is indeed Treponema pallidum requires that material be inoculated into a VDRLnonreactive rabbit, although an experienced syphilologist rarely needs to resort to this technique when diagnosing primary syphilis. Furthermore, dark-field examination is applicable only to suspected primary syphilis and the less common ulcerative lesions of secondary syphilis that occur on nonmucosal surfaces and could not have been applied to the patient presented in our report. However, a positive dark-field examination is tantamount to a microbiologic diagnosis in the appropriate setting; the introductory sentence to our case report would have been clearer had it referred to the manifestations of secondary and late syphilis. Justin D. Radolf, M.D. University of Texas Health Science Center at Dallas Dallas, TX 75235
Journal of the American Academy of Dermatology
Correspondence
department. Since the age of 5 he had flat, small plantar and palmar warts 2 to 3 mm in diameter that later extended to the dorsal surfaces of the hands, arms, and forehead. At the age of 20, he was the victim of a severe car accident in which he sustained a subdural hematoma and acute abdominal bleeding. In the course of surgical exploration, a subhepatic hematoma was drained and the patient was subsequently discharged. Later, he complained of headache and dizziness, which proved to be caused by a posterior fossa abscess and meningitis. Abdominal leakage was also detected and was found to originate in an abdominal abscess. Both abscesses were drained and repeated cultures from both sites revealed the presence of Cryptococcus infection. Although amphotericin B in daily doses of 40 mg improved the patient's general condition, the therapy was discontinued because of leucopenia and thrombocytopenia. Upon evaluation of the patient's immune profile, a normal percentage of T and B cells was found. Examination of the T subpopulation revealed a decrease in the number of T4 (helper) cells and a slight decline in the T4 to Ta ratio, which registered 0.6. The T cell response to mitogens, phytohemagglutinin, and concanavalin A, as well as the lymphocyte response to pokeweed mitogen, was slightly lowered.
Comment. Our results confirm the depressed cellmediated immunity observed by Majewski and colleagues in epidermodysplasia verruciformis. Seemingly, in our case of epidermodysplasia verruciformis, the patient's compromised immune system led to the complications encountered, following trauma.
Vera Leibovici, M.D., and Anda Kanner, M.D. Hadassah University Hospital Jerusalem, Israel
Unusual manifestations of syphilis with human immunodeficiency virus infection To the Editor." It is not necessary to be able to culture Treponerna pallidurn in order to make a microbiologic diagnosis of syphilis easily and commonly in a patient with the primary or secondary stage of the disease. Radolf and Kaplan open their report (J AM ACAD DER~thTOL 1988;18:423-7) as follows: "Microbiologic diagnosis of syphilitic infection is rarely accomplished because the etiologic agent, Treponema pallidum, cannot be cultivated in vitro." Anyone inexperienced in the diagnosis of early syphilis is misled by such a statement, because serum obtained from an early syphilitic cutaneous lesion or external genital mucous membrane lesion
(not the oral mucous membrane) will readily show many T. pallidurn spirochetes with their characteristic spiraling motion and stiff flexing attempts. A drop of normal saline onto a freshly denuded but not bleeding lesion is mixed with serous exudate and aspirated into a tuberculin syringe without a needle a regular wet mount using a clean unscratched slide and coverslip. Examination with a dark-field microscope will usually reveal myriad organisms. Thus microbiologic diagnosis of an early syphilitic lesion is accomplished in minutes in offices, laboratories, or clinics with a dark-field microscope. Serum from an oral lesion is useless because of residential oral spirochetes resembling T. pallidurn contaminating mouth lesions. Our board of health has a dark-field microscope.
William E. McDaniel, M.D. 342 Waller Ave., Lexington, K Y 40504
Reply To the Editor: Dr. McDaniel raises an important point in his comments on the opening sentence for our recent case report. His description of the appropriate technique for obtaining specimens for dark-field microscopy also is appreciated. However, a positive dark-field examination should not be equated with microbiologic confirmation; specimens containing both pathogenic and nonpathogenic treponemes (and even other spirochetes) can give positive dark-field examinations. Confirmation that the Organism visualized is indeed Treponema pallidum requires that material be inoculated into a VDRLnonreactive rabbit, although an experienced syphilologist rarely needs to resort to this technique when diagnosing primary syphilis. Furthermore, dark-field examination is applicable only to suspected primary syphilis and the less common ulcerative lesions of secondary syphilis that occur on nonmucosal surfaces and could not have been applied to the patient presented in our report. However, a positive dark-field examination is tantamount to a microbiologic diagnosis in the appropriate setting; the introductory sentence to our case report would have been clearer had it referred to the manifestations of secondary and late syphilis. Justin D. Radolf, M.D. University of Texas Health Science Center at Dallas Dallas, TX 75235