Calza, Anne-Marie

Kinloch, Sabine

Mainetti, Carlo

Salomon, Denis

Saurat, Jean-Hilaire

RERO DOC Digital Library

JID 1991:164 (September) Correspondence 615ReferencesI. Gonzalez -Rui z A, Ruiz-Palacios G . Entamoeba hartmanni: missing ormisidentified? J Infect Dis 1991 ;164:612-3 .2. del Muro R, Acosta E, Merino E, Glender W, Orti z-Ortiz L. Diagnosis ofintestinal amebiasis using salivary IgA antibody detection. J Infect Dis1990; 162:1360-4.3. Begg CB. Biases in the assessment of diagnostic tests . Stat Med1987;6:411-23.4. Gonzalez-Ruiz A. Revision del estado actual del diagnostico diferencialde las amibas en Mexico. Salud Publica Mex 1990:32 :589-96.Primary Human Immunodeficiency Virus InfectionMimicking SyphilisColleagues-Primary exposure to the human immunodefi-ciency virus (HIV) may lead to an acute infectious disease withskin involvement [1-4). In the first review, in 1985 [I), a rash ofa mononucleosis type predominantly located on the trunk waspresent in 50% of patients and seemed characteristic althoughnonspecific. We report a case with unusual dermatologic mani-festations that were initially mistaken for syphilis.In September 1990, a 39-year-old homosexual man was re-ferred to us with the diagnosis of secondary syphilis. He pre-sented with a 7-day history of three genital ulcers. A high feverbegan 5 days later, associated with arthralgias, odynophagia ,and a nonpruritic skin rash. Further inquiry disclosed unpro-tected orogenital sex with an unknown partner 17 and 32 daysbefore.Physical examination revealed a patient in good general con-dition, febrile at 39.5°C, with a widespread symmetric purplishpapular eruption in a linear distribution on his face, trunk, andproximal part of the four limbs and palms. Numerous painfuloval-shaped ulcers up to I em in diameter were seen on theoropharyngeal mucosa, including the tongue. On the penis, anoblong, nonindurated, painful chancre of 2.5 X I em with aclean base was surrounded by two similar smaller ulcerations.Serous exudate was not obtained when pressure was applied.The scrotal area was also covered by many shallow oval-shapederosions. Generalized lymphadenopathy was present, includingthe antecubital and epitrochlear areas. No hepatomegaly wasnoted, but a slightly enlarged spleen was felt. The rest of theclinical examination was unremarkable.Findings from laboratory evaluation revealed normal valuesfor sedimentation rate, hemoglobin, white blood count, and bio-chemical profile. Platelet count was 119,000/mm3•Repeated darkfield examinations for Treponema pallidum, di-rect examination and culture for Haemophilus ducreyi, and im-munofluorescence staining for herpesviruses (simplex and zos-ter) of the genital ulcer's base were all negative. Serum VDRLReprints or correspondence: Dr. A. M. Calza, Clinique de Dermatologie,Hopital Cantonal Un iversitaire, 1211 Geneve 4, Switzerland.The Journal of Infectious Diseases 1991;164:615-6© 1991 by The University of Chicago. All rights reserved.0022-1 899/9 I{6403-0036$0 I.005. Aceti A, Pennica A, Celestino D. et al. Salivary IgA antibody detectionin invasive amebiasis and in asymptomatic infection. J Infect Dis1991:164:613-4.6. Mestecky J. McGhee JR. Arnold RR, Michalek SM, Prince SJ. Babb JL.Selective induction of an immune response in human external secre-tions by ingestion of bacterial antigen. J Clin Invest 1978;61 :731-7.7. Czerkinsky C, Prince SJ, Michalek SM. et a l. IgA antibody producingcells in peripheral blood after antigen ingestion : evidence of a com-mon mucosal immune system in humans. Proc Nat! Acad Sci USA1987;84 :2449-53.test, fluorescent treponemal antibody test, and Treponema pal/i-dum hemagglutination assay done on several occasions re-mained unreactive. Serologic evaluations for cytomegalovirus.Toxoplasma gondii, Epstein-Barr virus, rubella, and hepatitis A(IgM) and hepatitis B (antigen) were negative. On the day ofreferral, search for anti-HlV antibody by screening ELISA andimmunoblotting tests was unsuccessful. In contrast, HIV p24antigen (HIVAG-I; Abbott, North Chicago) was detected in theserum at 39 ng/1. Lymphocyte count was 1113/mm J, with aCD4 count of 323/mm3 and CD8 count of 545/mm3•Major features of histologic examination were edema and aperivascular and perifollicular lymphocytic infiltrate in the der-mis. There was minimal basal and suprabasal spongiosis, withlymphocytic exocytosis and rare necrotic keratinocytes in theepidermis . On electron microscopy, cytoplasmic reticulotubularstructures were present in most lymphocytes and histiocytes andin rare keratinocytes and Langerhans cells. There was no evi-dence of viral particles either assembling or budding.The patient's illness resolved spontaneously within 2 weeks.Return to normal body temperature occurred on day 3 and reso-Figure 1. Genital ulcers in a patient with human immunodeficiency virusinfection.616 Correspondence JlD 1991; 164 (September)lution ofthe skin rash on day 7 and of the erosive lesions on day15. HIV antibodies appeared on day 7 and coincided with thedisappearance of p24 antigenemia on day 8.Previous reports have shown that an exanthem, located pre-dominantly on the face and trunk, is probably the most commonskin manifestation of primary HIV infection [1-4]. Several re-ports have mentioned oral, esophageal, or genital erosive lesions[3,5). In very rare cases [6-9], concurrent oral and genital ulcershave been documented, but they have often been considered aminor diagnostic feature because of their limited extent.Owing to the presence of general symptoms associated withmucosal erosive lesions and a skin rash, all suggestiveofsyphilis,the initial clinical picture was misleading [10). The incubationperiod, morphology, and location of the penile chancre (figureI) were all compatible with primary syphilis, although severalfeatures such as the multiplicity of lesions and the absence ofinduration made this diagnosis unlikely. The papular eruption,which involved the palms as well, could easily have been mis-taken for secondary syphilis, particularly as contaminationseemed to have occurred via the orogenital route, unusual forHIV. The diagnosis of primary HIV infection in our case was,however, confirmed by successive serologic investigations.This case reminds us that primary HIV infection must be in-cluded in the differential diagnosis ofgenital ulcers, particularlyif associated with a skin rash and oral lesions. The use of p24antigen is useful in this instance. Because of the clinical similari-ties with other sexually transmitted diseases such as herpes, syph-ilis, or H. ducreyi infection, these should be ruled out as well.Anne-Marie Calza, Sabine Kinloch, Carlo Mainetti,Denis Salomon, and Jean-Hilaire SauratUnusually High Level of a Tumor-Associated Antigenin the Serum of Human ImmunodeficiencyVirus-Seropositive IndividualsColleagues-A 90,000-Da molecular mass lipoprotein (90K)recognized by monoclonal antibody Sp-2 [I] has recently beenidentified in the sera ofpatients with breast or ovarian cancer orother malignant diseases [2-4]. The 90K, which is now beingbiochemically characterized, has an NH2-terminal amino acidsequence that does not resemble any protein for which sequenceinformation is available (unpublished data). In preparation for amulticenter study on 90K as a prognostic indicator in a broadrange of malignancies, we have obtained serum samples fromthree patients with human immunodeficiency virus (HIV)-re-lated Kaposi's sarcoma. We found that these sera had the high-est 90K-immunoreactive activity ever recorded in our labora-tory. This observation prompted us to investigate the role ofthisantigen in HIV infection.Reprints or correspondence: Dr. S. Iacobelli, Cattedra Oncologia Medica,Universita "G. D'Annunzio," Via dei Vestini 5, 66100 Chieti, Italy.The Journal of Infectious Diseases 1991;164:616-7© 1991 by The University of Chicago. All rights reserved.0022-1899/91/6403-0037$01.00Clinic ofDermatology. Hiipital Cantonal Universitaire,Geneva, SwitzerlandReferencesI. Cooper DA. Gold J. Maclean P, et al. Acute AIDS retrovirus infection:definition of clinical illness associated with seroconversion. Lancet1985;1:537-40.2. Kessler HA. Blaauw B, Spear J, Deborah AP, Falk LA, Landay A.Diagnosis of human immunodeficiency virus infection in seronega-tive homosexuals presenting with an acute viral syndrome. JAMA1987;258:1196-9.3. Tindall B, Barker S. Donovan B. et al. Characterization of the acuteclinical illness associated with human immunodeficiency virus infec-tion. Arch Intern Med 1988; 148:945-9.4. Gaines G. von Sydow M, Pehrson PO, Lundbergh P. Clinical picture ofprimary HIV infection presenting as a glandular-fever-like illness.BMJ 1988;297: 1363-8.5. Hulsebosch HJ. Claessen FAP, van Ginkel CJW. Kuiters GRR. Goud-smit J, Lange JMA. Human immunodeficiency exanthem. J AmAcad Dermatol 1990;23:483-6.6. Bratzke B. Orfanos CEo Akutes Prirnarstadium einer HIV infection undUbergang in AIDS mit Kaposi 24 Monate danach. Hautartzt1988;39:514-8.7. Picard C. Oberlin P, Lazareth B, Crickx B. Belaich S. Primo-infectionpar Ie virus de l'immunodeficience humaine. Ann Dermatol Vener-eoI1990;117:861-4.8. Biggar RJ, Johnson BK. Musoke SS, et al. Severe illness associated withappearance of antibody to human immunodeficiency virus in anAfrican. BMJ 1986;293:1210-1.9. Bratzke B, Eichhorn R. Hoffken G, et al. Akute Primarphase als Indika-tor der HIV -l-Infektion. Dtsch Med Wochenschr 1988; 113: 1312-6.10. Thin RT. Early syphilis in the adult. In: Holmes KK. Sexually transmit-ted diseases. New York: McGraw-Hili. 1990:221-30.Sera were obtained from 104 anti-HIV-positive subjects: 20were symptom-free and without decreases in CD4+ lymphocytenumber, 27 were also asymptomatic but had decreases in CD4+lymphocytes «500/ILI), II had lymphadenopathy syndrome,30 had AIDS-related complex, and 16 had frank AIDS. Controlsera were obtained from 62 anti-HI V-negative blood donorsTable 1. Levelsof90-kDa protein (90K) in human immunodefi-ciency virus (HIV)-seronegative and -seropositive subjects.90K (units/ml), No. (%)with 90KGroup No. mean ± SO > 1.7 units/rnlAnti-Hlv-negative 62 0.87 ± 0.56 3 (5)Anti-HIV-positive 104 2.65 ± 1.54 73 (70)Asymptomatic.CD4+ > 500//J.I 20 1.70 ± 0.81 8 (40)Asymptomatic,CD4+ < 500//J.I 27 2.12 ± 1.01 16 (59)LAS II 1.96 ± 1.16 7 (64)ARC 30 3.65 ± 1.83 28 (93)AIDS 16 3.31 ± 1.18 14 (87.5)NOTE. LAS = lymphadenopathy syndrome; ARC = AIDS-related complex.All means for anti-HI V-positive subjects and subgroups were significantlygreaterthan those for anti-HI V-negative subjects (P < .0001, analysis of variance).

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