惡性梅毒

資料來源：n engl j med 388;21 nejm.org 2023 年 5 月 25 日

一名 44 歲男性，有人類免疫缺陷病毒感染史，間歇性地接受抗反轉錄病毒治療，因 1 個月發熱和皮膚瘙癢病史而就診於傳染病門診。 他的體溫為38.3°C。 體檢值得注意的是四肢和頭皮上的黑褐色片狀斑塊。實驗室研究值得注意的是 CD4 細胞計數為每立方毫米 86 個（參考範圍為 414 至 1123）、病毒載量為每毫升 35,900 拷貝（參考值 <20）以及快速血漿反應素效價為 1:32。 梅毒螺旋體顆粒瀰漫聚集真皮淋巴細胞和組織細胞並與漿細胞混合浸潤。 診斷為惡性梅毒。 惡性梅毒是一種罕見的二期梅毒，主要影響免疫功能低下的人。 皮膚表現多種多樣，從結節性潰瘍病變到牡蠣殼樣結痂，後者在該患者中出現。 患者拒絕腰椎穿刺評估神經梅毒。 他也拒絕了青黴素脫敏處置，因為他有青黴素過敏史過去曾逅進行過。 靜脈注射頭孢曲松（Ceftriaxone）2 週後，皮損和發熱減輕。 在 3 個月的追蹤中，快速血漿反應素效價降至 1:2。  

DOI：10.1056/NEJMicm2213894

Malignant Syphilis

n engl j med 388;21 nejm.org May 25, 2023

A 44-year-old man with a history of human immunodeficiency virus infection and intermittent adherence to antiretroviral therapy presented to the infectious disease clinic with a 1-month history of fevers and pruritic skin lesions. His temperature was 38.3°C. Physical examination was notable for blackish-brown lamellated plaques on the limbs and scalp. Laboratory studies were notable for a CD4 cell count of 86 per cubic millimeter (reference range, 414 to 1123), a viral load of 35,900 copies per milliliter (reference value, <20) and a rapid plasma reagin titer of 1:32. A Treponema pallidum particle agglu-diffuse dermal lymphocytes and histiocytes admixed with a plasma-cell infiltrate. A diagnosis of malignant syphilis was made. Malignant syphilis is an uncommon form of secondary syphilis that primarily affects immunocompromised persons. The skin manifestations are varied, ranging from ulceronodular lesions to oyster shell–like crusts, the latter of which were seen in this patient. The patient declined a lumbar puncture to evaluate for neurosyphilis. He also declined penicillin desensitization, which had been offered because of his history of anaphylaxis to penicillin. After a 2-week course of intravenous ceftriaxone, the skin lesions and fevers abated. At a 3-month follow-up visit, the rapid plasma reagin titer had decreased to 1:2. 

DOI: 10.1056/NEJMicm2213894

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