TheThe Great Mimicker

Diagnostic dilemmasDr Olwen Williams OBEConsultant Physician –Sexual Health/HIVYsbyty Glan Clwyd, North Wales

Great Mimickers……………

Non-infectious

• Large B cell lymphoma

• Sarcoidosis

• Multiple sclerosis

• Coeliac disease

• Addison’s

• Amyloidosis

• Fibromyalgia

Infections

• Lyme disease

• Nocardosis

• Tuberculosis

• Brucellosis

• Malaria

• Meiliodosis

• HIV

• Syphilis

Great Mimickers………..

Syphilis

Syphilis –gender , sexual orientation & HIV status

4 HIV in the United Kingdom: 2014

Annual new HIV and AIDS diagnoses and deaths:

UK, 1981-2013

96,142individuals

living with HIV

97% on treatment99%

Undetectable Viral Load

8%Unaware Diagnosis

New HIV & AIDS diagnoses and deaths 1981-2018

4,453 new cases 2018

PrEP

National Issue

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/806076/Addressing_the_increase_in_syphilis_in_England_Action_Plan_June_2019.pdf

• Spirochaete -Treponema pallidum

• Cannot be cultivated

• Genome sequenced in 1998

• Humoral & cell-mediated immune response

• Endarteritis obliterans

• Untreated T. pallidum survives for decades

• Protective immunity –but re-infection occurs

• Transmission rate 20-60%

Pathophysiology

. Stages of Syphilis

Patrick O'Byrne, and Paul MacPherson BMJ 2019;365:bmj.l4159

©2019 by British Medical Journal Publishing Group

• Sexual History

who? where? when?

• Travel history

• Sexualised drug use & Recreational drug history

• HIV /BBV risk & testing history

Rule of thumb

• Confidential , private environment

• Safeguarding

• Language

• Gender /sexuality

www.bashh.org/guidlines

Is the clue in the history ?

Past medical history

• Hypertension

• Squamous cell carcinoma

• Indapamide

• Doxazosin

• Testogel

• Last STI/HIV screen 2001 -NAD

Heterosexual

• Last sexual contact within previous month @ sauna –female

• Previously married

• No male contacts

Rpt test HIV +ve 06/09

Syphilis serology requested

62 yr old male heterosexualOnline + HIV test 4/09

• CD4 540• Viral Load 11,508• Resistance testing –fully

susceptible virusMildly abnormal164

• Mildly abnormal LFT - GGT 164- ALT 47

• Hep B Ag –ve• Hep C –veRepeat tests 4/10

Starts 13/10Dolutegravir /Truvada for HIV

Investigations

BHIVA Guidelines www.bhiva.org

5 days later patient phones up

Rash

Hard lumps in testis

Thoughts ?

Findings

Widespread coppery rash bodyRash on palms & soles of feet

Hard craggy lesions around 1.5cm diamin both testis –unable to distinguish from testis .

Syphilis serology 6/09 Antibody +veTPPA –veRPR –ve

Single or multiple pathologies ?Rash• HIV seroconversion • Drug reaction• Secondary Syphilis• Other

• and what about the LFTs ??????

Testicular lesions• Malignancy - Primary

- Secondary• Non-Hodgkin’s Lymphoma• Sarcoidosis• Amyloidosis• Congenital Adrenal Hyperplasia• Syphilitic Orchitis

Differential diagnosis

SYPHILIS HIV

Time scale 9-90 days 7-28 days

Fever x xx

Fatigue x x

Myalgia xx x

Rash xxx 50-70% x

Pharyngitis - xxx

Chancre xxx -

Weight loss xx xx

Alopecia x 11% -

Lymphadenopathy xxx xxx

Opportunistic infections - x

Ophthalmic problems xx x

Hepatitis xx 10% xx

Meningitis /CNS sympt. xxx 25-60% x

Diarrhoea - x

Features ofEarly syphilis vs

HIV seroconversion

Repeat Syphilis

Urgent Urology OPD

U/S testis 3 heterogeneous lesions

• 10x9x7 mm R testis -? Breach tunica

• 7x6x4 mm L testis

• 7x6x4 mm R epididymis

• Tumour markers -normal

• Rectal biopsy –normal

CT Thorax abdomen pelvis with contrast

Clinical indication:Testicular lesions on ultrasound. ? Tumour. Staging examination.

Findings:1. A couple of subpleural nodules are seen within the left upper and lower lobes which measure up to 4 mm. The lungs are otherwise clear.2. No adenopathy within the thorax.3. Normal appearances of the solid viscera.4. The lower rectum appears slightly thick walled with some mild inflammatory change within the surrounding fat. Remainder of the bowel appears unremarkable.5. There are some small volume bilateral iliac chain and para-aortic lymph nodes but these all subcentimetre in size and not significant as per CT size criteria.6. Moderate OA change at L4-5 and mild OA change at L5-S1. No destructive bone lesion. Conclusion:The lower rectum appears slightly bulky with inflammatory change in the surrounding mesentery. PR examination is advised to rule out a lesion here. I can see no further significant abnormality.

Next steps

Time lapse

6/09 4/10 18/10 8/11 20/12

TPPA Neg 1:320 > 1:5120 1:1280 1:1280RPR Neg 1:32 1:128 1:32 1:4

GGT 164 482 358 153ALT 47 57 38 37

Interpretation of Syphilis Serology

Treatment

BenzathinePenicillin 2.4IU IM Single dose Jarisch-Herxheimer Reaction

FeverChillsRigorHypotension TachycardiaHyperventilationVasodilation

Flushing 50%-90%Myalgia

Patient made full recovery

Primary Syphilis

Primary chancres

Features of Secondary Syphilis

• Generalized symmetrical ‘bronze’ rash

• Lymphadenopathy

• Patchy alopecia

• Condylomata lata

• Oral lesions

• Eye manifestations

• Malaise

• Headache

• Anorexia

• Joint pain

• Fever

• Neck stiffnessConjunctivitis EpiscleritisInterstitial KeratitisUveitis

ChorioretinitisRetinitis

Syphilitic Posterior PlacoidChorioretinopathy

NEUROSYPHILIS

Rashes

• Macular

• Papular

• Follicular

• Lichenoid

• Vesicular

• Psoriasiform

• Corymbiform

Oral lesions Snail Track Ulcers

Mucous patches

Management

Untreated 40% will develop Tertiary Syphilis

Confirm diagnosis with Syphilis Serology

Consider Lumbar Puncture

Treat Benzyl Penicillin 2.4IU IM x1

Penicillin allergy Doxycycline 100mg

orally bd 14 days

Anticipate x 4 drop RPR

Partner notification

Follow up for 1 year

• ‘If you’ve never ordered Syphilis serology, then you’ve missed a case’

• Suspect Syphilis –test for Syphilis + HIV

• Suspect HIV –test for HIV + Syphilis

• Involve your GUM physician

Learning points

• O'Byrne,P .MacPherson,P. Syphilis BMJ 2019;365:bmj.l4159

• Nyatsanza,F. Tipple,C. Syphilis: presentations in general medicine Clinical Medicine 2016Vol16,No 2:184-8

• BASHH Clinical effectiveness guidelines: Syphilis www.bashh.org/guidelines

#FOAMed #MedEd #MedTwitter #MedicineisBrilliant

@BASHH_UK @GreenhousePeter @AchyutaNori @jackiecassell@DrVesSullivan @CrossmanJodie @libokecha @TeoWinterAndy@dornu_doc @Jcalcolado

References & Acknowledgements