Skip to main content Skip to main navigation menu Skip to site footer

Secondary syphilis mimicking mid-borderline leprosy in HIV-positive patient

  • Rheza Rahmadika Putra ,
  • Usman Hadi ,


Background: Syphilis increases the risk of HIV transmission. Coinfection of both infectious diseases potentially changes the presentation of mucocutaneous lesions and accelerates disease progression, complicating the diagnosis and treatment with standard regimens. In the case study, we present a case of secondary syphilis in an HIV-positive patient with clinical manifestations resembling mid-borderline leprosy.

Case presentation: A 23-year-old male patient was referred to the emergency care unit of Dr. Soetomo General Hospital with red spots on the palms of the hands and soles of the feet for the past four months. The skin manifestation first appeared as a single spot, grew over time with itch and pain. The patient had lost 15 kg of body weight in the last three months which was confirmed as HIV-positive. He was also treated for leprosy based on the skin manifestations ever since. There was no history of direct contact with leprosy patients. The patient admitted that he had sex with men in the last 3-4 years. The laboratory examination showed negative results for Mycobacterium leprae through skin biopsy and negative for IgM and IgG of anti-phenolic glycolipid-1 (PGL-1). The patient however was positive for syphilis due to high titers of venereal disease research laboratory/rapid plasma regain (VDRL/RPR) and treponema pallidum hemagglutination (TPHA), supported by histological findings. The patient’s condition improved after receiving penicillin benzathine G, the definitive treatment for syphilis.

Conclusion: Secondary syphilis is a great imitator to mid-borderline leprosy, especially in HIV patients. To avoid misdiagnosis and mistreatment, a careful physical and laboratory examination, including serology and histopathology, should be carried out.


  1. World Health Organization. WHO Guidelines for The Treatment of Treponema pallidum (syphilis). In: Research TDoRHa, editor. Geneva, Switzerland: World Health Organization Press; 2016. p. 1-60.
  2. Li X, Yang LG, Li J, Zhao XY, Wei CB, Li YY, et al. Syphilis in HIV/AIDS Patients [Internet]. Mucocutaneous Manifestations of HIV/AIDS. Springer Singapore; 2020. p. 105–24. Available from:
  3. Health Mo. Syphilis management guidelines for syphilis control in primary health care. Directorate General of Disease Control and Environmental Health; 2013.
  4. Fernandez-Nieto D, Ortega-Quijano D, Jimenez-Cauhe J, Fernandez-Gonzalez P, Moreno-Moreno E, Bea-Ardebol S. Secondary syphilis mimicking tuberculoid leprosy in an HIV-positive individual: a case report. Int J STD & AIDS [Internet]. 2019;30(12):1235–8. Available from:
  5. Gustina F, Legiawati L, Rihatmadja R, Daili SF. Syphilis in Human Immunodeficiency Virus infection. Media Dermato-Venereologica Indones. 2011;36:33-41.
  6. Tambe S, Zambare U, Nayak C. Nodulo-ulcerative and erythrodermic secondary syphilis in human immunodeficiency virus-infected individuals. Int J STD & AIDS [Internet]. 2019;30(5):505–8. Available from:
  7. Macdonald G. Harrison’s Internal Medicine, 17th edition. - by Fauci AS, Kasper DL, Longo L, Braunwald E, Hauser SL, Jameson JL, Loscalzo J. Intern Med J [Internet]. 2008;38(12):932. Available from:
  8. Harnanti DV, Hidayati AN, Miftahussurur M. Concomitant Sexually Transmitted Diseases In Patients With Diagnosed Hiv/Aids: A Retrospective Study. African J Infect Dis [Internet]. 2018;12(1S):83–9. Available from:
  9. Maskoep WI, Nasronudin N, Khairunisa S, Sudjarwo SA. The Influence of Anti-Hiv-1 Specific IgY In Inhibiting HIV-1 Infection in Binding Phase with Syncytium Examination of CD4 Receptor Density Using the Flowcytometry Method. Folia Medica Indones [Internet]. 2021;56(4):290. Available from:
  10. Health Mo. National Guidelines for HIV Management Medical Services. Jakarta: Ministry of Health Republic of Indonesia; 2019.
  11. Farrar J, Hotez PJ, Junghanss T, Kang G, Lalloo D, White NJ. Preface to the Twenty-Third Edition [Internet]. Manson’s Tropical Infectious Diseases. Elsevier; 2014. p. xi. Available from:
  12. World Health Organiazation. WHO Case Definitions of HIV for Surveillance and Revised Clinical Staging and Immunological Classification of HIV-Related Disease in Adults and Children. Geneva: World Health Organization; 2007.
  13. Juanita L, Hadi U, Arfijanto V. Association Between Neopterin Levels and Outcome in 30 Day HIV/AIDS Naive Patients. Biomol Heal Sci J [Internet]. 2019;2(2):102. Available from:
  14. Çakmak SK, Tamer E, Karadağ AS, Waugh M. Syphilis: A great imitator. Clin Dermatol [Internet]. 2019;37(3):182–91. Available from:
  15. Carlson JA, Dabiri G, Cribier B, Sell S. The immunopathobiology of syphilis: the manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J Dermatopathol [Internet]. 2011;33(5):433–60. Available from:
  16. Lukehart SA. Syphilis. In: Jameson JL, Kasper, D.L., Longo, D.L., Fauci, A.S., Hauser, S.L., Loscalzo, J., ed. Harrison’s Principles of Internal Medicine 20th Edition. New York: McGraw Hill Education; 2018: 1279–85.
  17. Kenyon C, Osbak KK, Crucitti T, Kestens L. The immunological response to syphilis differs by HIV status; a prospective observational cohort study. BMC Infect Dis [Internet]. 2017 Jan 31;17(1):111. Available from:
  18. Liu XK, Li J. Histologic Features of Secondary Syphilis. Dermatology [Internet]. 2019;236(2):145–50. Available from:
  19. Avelar Pires CA, Soares JCM, Lopes dos Santos MA, Cordeiro HP, Campos Lodi VJ, Couto Rocha RP do, et al. Leprosy in a Patient Coinfected with HIV and Syphilis. Am J Infect Dis [Internet]. 2019;15(2):72–7. Available from:
  20. Walker SL, Withingtong, S.G., Lockwood, D.N. Leprosy. In: Farrar J, Hotez, P.J., Junghanss, T., Kang, G., Lalloo, D., White, N.J., ed. Manson’s Tropical Diseases. United Kingdom: Elsevier Saunders; 2014: 506–18.
  21. Wardiana M, Prakoeswa CRS, Sawitri R, Astari L, Prasetyo B, Budiono HAN. Dealing with tests and treatments for HIV, syphilis, and hepatitis B infection to prevent mother-to-child transmission (MTCT) from a tertiary hospital in Indonesia. Bali Med J. 2022;11:334–40.
  22. Costa-Silva M, Azevedo C, Azevedo F, Lisboa C. Early syphilis treatment in HIV-infected patients: single dose vs. three doses of benzathine penicillin G. J Eur Acad Dermatology Venereol [Internet]. 2016;30(10):1805–9. Available from:
  23. Muliawan P, Sawitri AAS. Prevalence of HIV Infection Among Tuberculosis Patients in Bali, Indonesia. Bali Med J [Internet]. 2016;5(1):75. Available from:

How to Cite

Putra, R. R., & Hadi, U. . (2022). Secondary syphilis mimicking mid-borderline leprosy in HIV-positive patient. Bali Medical Journal, 11(3), 1789–1794.




Search Panel