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CASE LETTER

Secondary Mimicking Molluscum Contagiosum in the Beard Area of an AIDS Patient

Kelly Brown, DO; Michael Koren, MD; Nicole M. Cassler, MD; George W. Turiansky, MD

and nodules localized to the left and right beard areas (Figure 1A). A few discrete, 2- to 5-mm, umbilicated PRACTICE POINTS papules were notedcopy in the right beard area (Figure 1B), • Recognize typical and atypical presentations of sec- as well as on the right side of the neck (Figure 1C), but- ondary syphilis (SS). tocks, and legs. Mild with yellow-white scale • This case reinforces the importance of cutaneous was present in the alar creases. Examination of the oro- in immunocompromised patients. pharyngeal mucosa revealed multiple thick white plaques • Consider the possibility of autoinoculation in SS. thatnot were easily scraped off with a tongue depressor. Examination of the palms, soles, and anogenital areas was normal. Do A punch of a nonumbilicated hyperkeratotic To the Editor: from the left beard area demonstrated spongiosis; A 46-year-old man with a history of AIDS (viral load, neutrophilic microabscess formation; plasma cells; and 28,186 copies/mL; CD4 count, 22 cells/μL) presented a superficial and deep perivascular, predominantly lym- with a 40-lb weight loss over the last 6 months as well phohistiocytic infiltrate (Figure 2A). Spirochete immu- as dysphagia and a new-onset pruritic facial eruption of nohistochemical staining of tissue highlighted abundant 1 week’s duration. The facial quickly spread to organisms in the dermoepidermal junction and vascular involve the beard area and the upper neck. His medical endothelial cells (Figure 2B). Other tissue stains for bac- history was notable for nicotine dependence, sebor- teria, including acid-fast bacilli, and fungi were negative. rheic , molluscum CUTIScontagiosum (MC), treated Bacterial culture of tissue from the in the left beard neurosyphilis and latent tuberculosis, hypertension, area grew Staphylococcus aureus. Results of acid-fast and a liver mass suspected to be a hemangioma, and erythro- fungal cultures of tissue were negative. Shave biopsy cytosis. He was diagnosed with human immunodeficiency of the umbilicated papule on the right side of the infection 19 years prior to presentation and was neck demonstrated classic invagination of the not compliant with the prescribed highly active antiret- into the and intracytoplasmic viral inclusions roviral therapy. consistent with MC (Figure 2C). Spirochete immunohis- examination revealed multiple discrete and tochemical staining of the same tissue sample was nega- coalescing, 2- to 12-mm, nonumbilicated, hyperkeratotic tive (Figure 2D).

Dr. Brown is from the Department of Family Medicine, Naval Branch Health Clinic Indian Head, Maryland. Dr. Koren is from the Department of Infectious Disease, Walter Reed National Military Medical Center, Bethesda, Maryland. Dr. Cassler is from the Department of , Naval Hospital Bremerton, Washington. Dr. Turiansky is from the Department of Dermatology, Uniformed Services University of the Health Sciences, Bethesda. The authors report no conflict of interest. The views expressed in this article are those of the authors and do not reflect the official policy of the US Department of the Army, US Department of the Navy, US Department of Defense, or the US Government. This case was presented in part at the 23rd World Congress of Dermatology; June 8-13, 2015; Vancouver, British Columbia, Canada. Correspondence: Kelly Brown, DO ([email protected]).

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A B C

FIGURE 1. A, Grouped, hyperkeratotic, nonumbilicated papules and nodules on the left beard area. B, Rare umbilicated papules were noted in the right beard area. C, An umbilicated papule also was observed on the right side of the neck.

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A C

CUTIS

B D

FIGURE 2. A, A punch biopsy of a lesion from the left beard area demonstrated spongiosis; neutrophilic microabscess formation; plasma cells; and a superficial and deep perivascular, predominantly lymphohistiocytic infiltrate (H&E, original magnification ×100). B, Spirochete immunohisto- chemical staining of tissue highlighted abundant organisms in the dermoepidermal junction and vascular endothelial cells (H&E, original magnifi- cation ×400). C, Shave biopsy of the umbilicated papule on the right side of the neck demonstrated classic invagination of the epidermis into the dermis and intracytoplasmic viral inclusions consistent with molluscum contagiosum (H&E, original magnification ×40). D, Spirochete immunohis- tochemical staining of the umbilicated papule on the right side of the neck was negative (original magnification ×200).

WWW.MDEDGE.COM/CUTIS VOL. 104 NO. 4 I OCTOBER 2019 E19 Copyright Cutis 2019. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. SECONDARY SYPHILIS MIMICKING MOLLUSCUM CONTAGIOSUM

Serum rapid plasma reagin was reactive with a titer The for hyperkeratotic papules of 1:128 compared to the last known reactive rapid and nodules localized to the beard area in human immu- plasma reagin titer of 1:1 five years prior to presentation. nodeficiency virus–infected males includes MC, verruca A fluorescent treponemal antibody absorption test and vulgaris, chronic verrucous varicella-zoster virus, crusted VDRL test of cerebrospinal fluid was nonreactive. Fungal, , tuberculosis verrucosa cutis, hypertrophic lichen bacterial, and acid-fast cultures of cerebral spinal fluid planus, and disseminated deep fungal infections including and a cryptococcal antigen test were negative. Serum and . In the setting of cryptococcal antigen and coccidioides complement fixa- , the diagnosis of hyperkeratotic MC tion tests were negative. plasma poly- was favored in our patient given the co-location of classic merase chain reaction and urine histoplasma antigen umbilicated MC lesions with the hyperkeratotic papules testing were negative. Computed tomography of the and nodules. It is common to see MC autoinoculated in chest revealed a new 1.9×1.6×2.1-cm3 cavitary lesion the beard area in men from shaving, as well as for MC with distal tree-in-bud opacities in the lingula of the left to present in an atypical manner, particularly as hyper- lung. Acid-fast blood culture was negative, and acid-fast keratotic lesions, in patients with AIDS.4 The predominant sputum culture was positive for Mycobacterium kansasii. localized beard distribution and lack of other mucocutane- The cutaneous pathology findings and serologic find- ous manifestations of SS at presentation supported a clini- ings confirmed the diagnoses of cutaneous secondary cal diagnosis of hyperkeratotic MC in our patient. syphilis (SS) in the beard area and MC on the right side of Unique presentations of SS have been documented, the neck. Clinical diagnoses of seborrheic dermatitis of the including nodular lesions of the face, but they typically alar creases and esophageal also were made. have been accompanied by other stigmata of SS such as The patient was treated with intramuscular penicillin G the classic palmoplantar or truncal maculopapular .3 2.4 million U once weekly for 3 weeks. The lesions con- One notable difference in our case was the localized fined to the beard area rapidly resolved within 7 days after beard distributioncopy of the syphilitic cutaneous lesions in the first dose of antibiotics, which further supported the a man with AIDS. Our case reinforces the importance of diagnosis of localized cutaneous SS. Fluconazole 100 mg cutaneous biopsies in immunocompromised patients. It once daily was prescribed for the esophageal candidiasis, is known that SS spreads hematogenously; however, in and he also was started on a regimen of rifampin 600 mg our case it was suspected that the new lesions may have once daily, isoniazid 300 mg once daily, ethambutol 1200 mg spreadnot locally through autoinoculation via beard hair once daily, and pyrazinamide 1500 mg once daily. removal, as the hyperkeratotic lesions were limited to the Syphilis is well known as the great masquerader beard area. Koebnerization secondary to trauma induced due to its many possible manifestations. Many patientsDo by beard hair removal was considered in this case; how- present with typical palmar and plantar dermatoses.1 ever, koebnerization is known to occur in noninfectious Other documented SS presentations include eruptions dermatologic conditions, such as , , ranging from a few to diffusely disseminated maculo- , and , but not in infections such as papular lesions with or without scale on the trunk and syphilis. Our case is pivotal in raising the question of upper extremities; pustular and nodular lesions of the whether SS can be autoinoculated in the beard area. face; alopecia; grayish white patches on the ; and ulcerative, psoriasiform, follicular, and lichenoid REFERENCES lesions.2 Cutaneous SS has not been commonly reported 1. Baughn RE, Musher DM. Secondary syphilitic lesions. Clin Microbiol CUTIS Rev. 2005;18:205-216. in a localized distribution to the beard area with a clini- 2. Dourmishev LA, Dourmishev AL. Syphilis: uncommon presentations cal appearance mimicking hyperkeratotic MC lesions.3 in adults. Clin Dermatol. 2005;23:555-564. Secondary syphilis is not known to spread through auto- 3. Cohen SE, Klausner JD, Engelman J, et al. Syphilis in the modern inoculation, presumably from shaving (as in our case), as era: an update for physicians. Infect Dis Clin North Am. 2013; 27:705-722. might occur with other cutaneous infectious processes 4. Filo-Rogulska M, Pindycka-Plaszcznska M, Januszewski K, et al. such as MC, verruca vulgaris, S aureus, and dermatophy- Disseminated atypical molluscum contagiosum as a presenting tosis in the beard area. symptom of HIV infection. Postepy Dermatol Alergol. 2013;30:56-58.

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