Secondary Syphilis Presenting as Cutaneous T‐Cell Lymphoma in an HIV‐Positive Patient

We present the case of an HIV‐positive 38‐year‐old Caucasian male with a history of fevers, chills, and disseminated nonpruritic erythematous papules that began on his abdomen. An initial skin biopsy revealed a lymphohistiocytic infiltrate at the dermoepidermal junction, exocytosis of atypical lymphocytes, and minimal spongiosis. Immunohistochemistry showed increased CD8‐positive cells but only scattered CD30‐positive cells. PCR analysis demonstrated T‐cell receptor gamma gene rearrangement. RPR, blood and tissue cultures were all negative. The patient was thought to have a cytotoxic cutaneous T‐cell lymphoma. Over time, the lesions progressed to the palms and soles and the patient remained febrile. Repeat biopsy demonstrated a lichenoid interface dermatitis with a superficial and deep perivascular, interstitial, and periadnexal lymphohistiocytic infiltrate and the formation of epithelioid granulomas throughout the dermis. The epidermis showed blurring of the dermoepidermal junction, spongiosis, and exocytosis of lymphocytes and neutrophils. Few spirochetes were demonstrated by Steiner stain. Repeat RPR and FTA‐Abs serologies were positive. The patient was diagnosed with late secondary syphilis and was successfully treated with benzathine penicillin. This case demonstrates that atypical lymphoid infiltrates can simulate mycosis fungoides in an HIV‐positive patient with secondary syphilis and also reiterates that syphilis is a great mimicker of other entities.