Careers  |  Sign In  |  Register  |   Twitter

60-Year-Old Female with Lesion at Corner of Her Lips

Can you diagnose this case?

Seme Tabassum, MD; Rajasingam Jayasingam, MD; and Jin S. Suh, MD

Signs and Symptoms

A 60-year-old woman with a history of HIV/AIDS who was nonadherent with her highly active antiretroviral therapy presented to an outpatient clinic for a follow-up appointment. She was noted to have a lesion at the corner of her lips, which she reported having been present for at least 1 month. She denied fevers, chills, or any other dermatologic manifestations on her body.

On physical examination, a well-defined, warty plaque with a “split pea” appearance was present at the left commissure of her lips. The lesion was painless and nonpruritic.

Laboratory test results showed an HIV RNA viral load of 98,550 copies/mL and a CD4 count of 174 cells/mm3. Upon further questioning, the patient admitted to poor adherence with her HIV medications and having engaged in unprotected sexual intercourse for past several months.

What is responsible for the woman’s lesion?

Choose one to reveal diagnosis and discussion

Condyloma acuminatum
Secondary syphilis
Herpes labialis
Complex aphthosis
Behçet disease

Answer: Secondary syphilis

See the full case at Consultant360

A 60-year-old woman with a history of HIV/AIDS who was nonadherent with her highly active antiretroviral therapy presented to an outpatient clinic for a follow-up appointment. She was noted to have a lesion at the corner of her lips, which she reported having been present for at least 1 month. She denied fevers, chills, or any other dermatologic manifestations on her body. On physical examination, a well-defined, warty plaque with a “split pea” appearance was present at the left commissure of her lips. The lesion was painless and nonpruritic.

Laboratory test results showed that she had an HIV RNA viral load of 98,550 copies/mL and a CD4 count of 174 cells/mm3. Upon further questioning, the patient admitted to poor adherence with her HIV medications and having engaged in unprotected sexual intercourse for past several months.

This patient’s initial clinical presentation is highly suspicious for secondary syphilis, as her “split-pea” rash is a rare manifestation of the disease.

Follow-up laboratory testing showed her syphilis rapid plasma reagin (RPR) titer to be 1:64; she had been previously been nonreactive. Results of screening tests for chlamydia and gonorrhea were negative. She was treated with 2.4 million units of intramuscular penicillin G benzathine weekly for 3 weeks. Over the course of following 2 months, her lesion resolved completely, and her RPR titer decreased to 1:4.

DISCUSSION

Syphilis is a vastly spreading sexually transmitted disease with serious health implications if left untreated. According to the Centers for Disease Control and Prevention, the US syphilis rate reached a peak in 2014 after having hit a historic low in 2001; since 2013, the syphilis rate in the female population has particularly increased, leading to increases in the number of newborns with congenital syphilis.1 It is therefore important to recognize signs and symptoms of the disease for the initiation of treatment. Dermatologic manifestations of syphilis are important diagnostic clues, because they may provide clinical details about the stage of the disease.

Rash is the most characteristic finding in cases of secondary syphilis. It usually occurs 3 to 6 weeks after the initial painless chancre develops in primary syphilis due to the hematogenous spread of the Treponema pallidum bacteria.2 Secondary syphilis can present in a variety of forms, including mucous patches, condylomata lata, and oral manifestations.

In warm and moist areas of the body such as the genitals, perineum, perianal region, and axillary and groin areas, the skin and mucosal lesions of secondary syphilis may proliferate into pale, elevated, moist, sharply demarcated papules with flat surfaces known as condyloma lata.2,3 These highly infectious lesions are seen in 25% to 60% of patients with secondary syphilis. When present at the labial and nasolabial folds, these lesions may become elevated and fissured, known as split papules.3 As illustrated by our patient’s case, the split papule is a raised papular lesion at the commissure of the lip, with a fissure separating the upper and lower lip, giving “split pea” appearance. Histologically, the lesions exhibit endothelial proliferation, swelling, and perivascular chronic inflammatory cell infiltration.4 The split papule is highly contagious, and patients may also present with other manifestations including fevers, lymphadenopathy, and fatigue.5

Recognizing the split-pea lesions allows for a high index of clinical suspicion for secondary syphilis, leading to further investigation, diagnosis, and treatment. This can spare patients the detrimental cardiac and neurologic complications associated with the progression to tertiary syphilis if left untreated, as well prevent horizontal and vertical disease transmission.

References:

1. Centers for Disease Control and Prevention. Changing the Story of Syphilis. https://www.cdc.gov/std/products/success/changing-the-story-of-syphilis-success-story-508c.pdf, Accessed April 21, 2017/

2. Hicks CB, Clement M. Syphilis: epidemiology, pathophysiology, and clinical manifestations in HIV-uninfected patients. UpToDate. http://www.uptodate.com/contents/syphilis-epidemiology-pathophysiology-and-clinical-manifestations-in-hiv-uninfected-patients, November 21, 2016. Accessed April 21, 2017.

3. French P, Gupta S, Kumar B. Infectious syphilis. In: Gupta S, Kumar B, eds. Sexually Transmitted Infections. 2nd ed. New Delhi, India: Elsevier; 2012:429-457.

4. Bacterial infections. In: Ghom A, Mhaske S. Textbook of Oral Pathology. New Delhi, India: Jaypee Brothers Medical Publishers; 2008:461-483.

5. Brown DL, Frank JE. Diagnosis and management of syphilis. Am Fam Physician. 2003;68(2):283-290.

More Cases
45-Year-Old Female with Asymptomatic Solitary Papule

Can you identify this skin ailment? Take this week's Derm Case Challenge to validate your diagnosis.

45-Year-Old Female with Asymptomatic Solitary Papule
38-Year-Old Male with Left Thumb Lesion

Derm Case Challenge

38-Year-Old Male with Left Thumb Lesion
75-Year-Old Female with Rash on Lower Extremities

Test your dermatology knowledge with this week's Derm Case Challenge.

75-Year-Old Female with Rash on Lower Extremities
40-Year-Old Male with Growing Lesion on Back

Can you identify this skin ailment? Take this week's Derm Case Challenge to validate your diagnosis.

40-Year-Old Male with Growing Lesion on Back
45-Year-Old Male with Photodistributed Rash

Derm Case Challenge

45-Year-Old Male with Photodistributed Rash
46-Year-Old Female with Knee and Lower Back Aches

Derm Case Challenge

46-Year-Old Female with Knee and Lower Back Aches
75-Year-Old Female with Rash on Lower Extremities

Test your dermatology knowledge with this week's Derm Case Challenge.

75-Year-Old Female with Rash on Lower Extremities
40-Year-Old Female with Inframammary Rash

Derm Case Challenge

40-Year-Old Female with Inframammary Rash
42-Year-Old Male with Abnormal-Looking Thumbnails

Test your dermatology knowledge with this week's Derm Case Challenge.

42-Year-Old Male with Abnormal-Looking Thumbnails
27-Year-Old Male with Bumps on Scalp and Neck

Derm Case Challenge

27-Year-Old Male with Bumps on Scalp and Neck