LAUSR

A 31-year-old man with a history of epilepsy (treated with valproic acid), alcoholism, and drug addiction visited the dermatology department with a mildly pruritic skin condition that had first appeared 45 days earlier on the forehead before spreading to the rest of his body. The patient also complained of general malaise. The physical examination revealed a disseminated rash characterized by smooth, well-defined, erythematousviolaceous nodules and papules with peripheral collarette scaling, some of which coalesced to form plaques. Welldefined ulcers with a violaceous border and dirty base were found on the back and left thigh. These were painful to touch (Fig. 1). Microscopy with hematoxylin-eosin staining revealed ulceration of the epidermis, acanthosis, spongiosis, and a damaged basal layer, with microabscesses that open to the surface. A nodular, perivascular, and periadnexal inflammatory infiltrate comprising mainly plasma cells, lymphocytes, and histiocytes was observed in the superficial and deep dermis. These findings were compatible with secondary syphilis. Warthin-Starry, May-Grünwald, and Giemsa staining did not reveal spirochetes. The significant laboratory findings were as follows: venereal disease research laboratory (VDRL) test, positive (1/16 dilution); human immunodeficiency virus (HIV) p24 antigen assay, 482.80; CD4, 120 cells/ L; viral load, 2150 copies/mL; syphilis, 205.20. The patient was diagnosed with malignant syphilis and HIV infection and prescribed benzathine penicillin 2 400 000 IU per week for 3 weeks. The treatment led to a self-limiting Jarisch-Herxheimer reaction that did not require treatment.