Article
A 58-year-old MSM (man who has sex with men) HIV +ve patient presented with asyptomatic lesions on his tongue over one week. Clinical intra-oral examination revealed only two superficial ulcerations covered with whitish pseudomembrane and located in the dorsum (Figure 1) and in the ventral surface of his tongue. These ulcers had an erythematous base and smooth regular margins with normal surrounding tissues and were soft and painless in palpation. Extra-oral examination revealed systemic lymphadenopathy, mainly in the neck and groin area where multiple erythematous plaques with erosions on the scrotum were found (Figure 2). Fever, malaise or other general symptoms were not recorded.
This man was a chronic smoker but rarely a drinker and took only antihypertensive drugs. He was under a close follow-up for his HIV infection but without drugs. He had undergone investigations which showed a negative pathergy test, negative desmoglein antibodies 1 and 3 but positive FTA antibodies.
Q1. What is the likely diagnosis?
A1. The answer to what is the likely diagnosis?
This man suffered from secondary syphilis confirmed by the presence clinically of asymptomatic atypical ulcerations in his mouth and groins together with lymphadenopathy and his highly positive Fluorescent Treponemal Antibodies (FTAs). Behçet's syndrome usually occurs in young males with a history of painful oral aphthae-like lesions, genital ulcerations and eye problems (iritis, uveitis or conjunctivitis). The absence of desmoglein antibodies and the lack of severe oral and skin lesions, together with the lack of drug use by the patient, help to exclude pemphigus vulgaris or Stevens-Johnson syndrome, respectively. The lack of joint redness, swelling and pain in knees, ankles or feet and circinate balanitis on the penis or keratoderma blenorrhagica on palms and soles excludes Reiter syndrome.
Q2. Which of the blood tests below for syphilis has higher false positive results?
A2. The answer to which of the blood tests below for syphilis has higher false positive results?
VDRL is a non-treponema specific test positive in syphilis but can also be positive in some older patients or in pregnant women, as well as in patients with pathological conditions such as other infections (bacterial endocarditis, hepatitis, infective mononucleosis, yaws or pinta), in various malignancies, or in skin diseases such as lupus erythematosus, scleroderma and leprosy. A positive VDRL result must therefore be confirmed by specific tests such as: FTA, which is highly positive after 3–4 weeks after spirochaete exposure; and EIA, which is an indirect method for the detection of IgG Abs to Treponema Pallidum (cut off>0.381).