A Diffuse Rash in a Patient Infected with HIV

Keywords: Syphilis; Treponema pallidum; HIV.

A 27-year-old MSM, presented to care with a rash. The rash appeared several weeks prior to presentation and involved the face, chest and back, arms and legs and was not accompanied by pruritus. He denied fever, chills, but complained of fatigue. No respiratory, gastrointestinal or urinary symptoms were present. He disclosed a diagnosis of HIV infection a year earlier, but has not kept his follow up appointments and was not receiving anti-retroviral medications or opportunistic infection prophylaxis. His most recent CD4 count was 109/mm3. He admitted sexual encounters with several male partners with inconsistent condom usage, and recalled a penile lesion that was present several weeks before the rash had appeared. The lesion has healed without specific therapy.

On physical examination: in no apparent distress, vital signs were within normal limits.

Notable finding on the examination included multiple small and non-tender anterior cervical, posterior cervical, axillary and inguinal lymph nodes. Genital examination revealed a healed lesion on the glans penis. A macular skin rash was widely distributed over face, trunk and extremities with several lesions on palms and soles (figure 1. and 2.)

1. What is your diagnosis?
2. Would you obtain a lumbar puncture?