J AM ACAD DERMATOL

VOLUME 70, NUMBER 6

Letters e131

significant study in this field has been reported for

autoimmune bullous diseases.
IgG recognition of extracellular domains of BP180
was also reported to be an early and crucial event in
development of BP, followed by ES events toward
intracytoplasmic domain of BP180 and BP230.5 Our
case showed IgG and IgA reactivity with various
extracellular domains of BP180, without reactivity
with BP230.
Manabu Osawa, MD,a Ikuko Ueda-Hayakawa, MD,
PhD,a Taiki Isei, MD, PhD,a Ken Yoshimura,
MD, PhD,b Shunpei Fukuda, MD, PhD,c Takashi
Hashimoto, MD,c,d and Hiroyuki Okamoto,
MD, PhDa
Department of Dermatologya and Department of
Pediatric,b Kansai Medical University, Hirakata;
Department of Dermatology,c Kurume University
School of Medicine, and Kurume University
Institute of Cutaneous Cell Biology,d Japan
Funding sources: None.
Conflicts of interest: None declared.
Correspondence to: Manabu Osawa, MD, Department of Dermatology, Kansai Medical University,
15-10, Sonoda-Cho, Moriguchi, Osaka, Japan
570-8507
E-mail: osawam@hirakata.kmu.ac.jp
REFERENCES
1. Korman N. Bullous pemphigoid. J Am Acad Dermatol 1987;16:
907-24.
2. Matsumura K, Amagai M, Nishikawa T, Hashimoto T. The
majority of bullous pemphigoid and herpes gestationis serum
samples react with the NC16a domain of the 180-kDa bullous
pemphigoid antigen. Arch Dermatol Res 1996;288:507-9.
3. Nie Z, Hashimoto T. IgA antibodies of cicatricial pemphigoid
sera specifically react with C-terminus of BP180. J Invest
Dermatol 1999;112:254-5.
4. Ishii N, Ohyama B, Yamaguchi Z, Hashimoto T. IgA autoantibodies against the NC16a domain of BP180 but not 120-kDa
LAD-1 detected in a patient with linear IgA disease. Br J
Dermatol 2008;158:1151-3.
5. Di Zenzo G, Thoma-Uszynski S, Calabresi V, Fontao L, Hofmann
SC, Lacour JP, et al. Demonstration of epitope-spreading
phenomena in bullous pemphigoid: results of a prospective
multicenter study. J Invest Dermatol 2011;131:2271-80.
http://dx.doi.org/10.1016/j.jaad.2013.06.006

Clavi syphiliticiean unusual presentation of

syphilis
To the Editor: The clinical manifestations of syphilis,
often described as the great imitator, are varied and
may be neglected or confused with other diseases.1

Fig 1. Clavi syphilitici. Palmar hyperkeratotic plaques and

erythematous papules.

Furthermore, in patients with human immunodeficiency virus (HIV), infections often exhibit unusual
features.2
A 24-year-old man was referred to our department
for a 6-month history of warty lesions on the palms
and soles, unresponsive to keratolytic treatment. He
reported having sex with men, 3 sexual partners
during the past year, and inconsistent condom use.
Latent syphilis and HIV infection had been diagnosed
4 years earlier after screening analysis and, at that
time, he was appropriately treated with penicillin.
Clinical examination revealed well-demarcated
hyperkeratotic plaques and some erythematous
macules and papules on the palms and on the soles
(Fig 1). Exudative pink papules were observed on
the scrotum and violet-brown macular plaques were
present in the perianal region.
A biopsy specimen of a palmar lesion demonstrated hyperkeratosis and a dermal polymorphic
infiltrate with histiocytes, plasma cells, and lymphocytes. Warthin-Starry stain did not demonstrate
microorganisms, but polymerase chain reaction was
positive for Treponema pallidum in the skin lesion
sample. Histologic examination of the perianal lesions was consistent with the diagnosis of condyloma
acuminata. Routine laboratory tests were normal and
tests for hepatitis A, B, and C were negative. HIV viral
load was 50,990 copies/mL and CD4 cell count was
308 cell/mm3 (normal range: 500-1000 cells/mm3).
A positive Venereal Disease Research Laboratory
test (titer 1:32) and a reactive Treponema
pallidum particle agglutination assay were obtained,
supporting the diagnosis of secondary syphilis.
Treatment was performed with a single intramuscular dose of benzathine penicillin (2,400,000 U).
Rapid regression of palmoplantar and scrotal lesions

e132 Letters

J AM ACAD DERMATOL

JUNE 2014

Conflict of interest: None declared.

Corresponding author: Catarina Moreira, MD,
Department of Dermatology and Venereology,
Centro Hospitalar S~
ao Jo~
ao EPE, Porto, Portugal
E-mail: cat_moreira@netcabo.pt

Fig 2. Clavi syphilitici. Clinical appearance of palmar

lesions 1 month after penicillin treatment.

was observed after the penicillin treatment (Fig 2).

The patient underwent proctologic examination,
which showed no further alterations in addition to
perianal condyloma acuminata, and cryosurgery of
those lesions was performed.
The multiple and atypical manifestations of
secondary syphilis in patients with HIV may result
in a misdiagnosis and inappropriate treatment.
In the literature, there are few reports of palmar
and plantar hyperkeratotic lesions of secondary
syphilis,3,4 some of which can mimic and be
confused with viral warts or calluses, classically
known as clavi syphilitici.5
In the described case, the combination of
palmar-plantar lesions, detection of Treponema
pallidum by molecular biology, positive serology
for syphilis, and rapid response to treatment with
penicillin was consistent with a diagnosis of secondary syphilis.
We present this case to illustrate a rare and
potentially confounding clinical manifestation of
syphilis, a disease that is still very present in medical
practice. We also intend to emphasize that the
acquisition of another sexually transmitted infection
(STI) by a patient with HIV is a public health problem
because it means the maintenance of risk behaviors
that enhance the transmission of these diseases. For
the patient, the infection with an STI is a risk factor
for other STIs, so in individuals with HIV, syphilis
should be included in the differential diagnosis of
new skin and mucosal lesions or those unresponsive
to conventional therapy.
Catarina Moreira, MD,a Ana F. Pedrosa, MD,a
Carmen Lisboa, PhD,a,b and Filomena Azevedo,
MDa
Department of Dermatology and Venereology,a
Centro Hospitalar S~
ao Jo~
ao EPE, and Faculty of
Medicine,b University of Porto, Portugal
Funding sources: None.

REFERENCES
1. Domantay-Apostol GP, Handog EB, Gabriel MT. Syphilis: the
international challenge of the great imitator. Dermatol Clin
2008;26:191-202.
2. Gregory N, Sanchez M, Buchness MR. The spectrum of syphilis
in patients with human immunodeficiency virus infection. J Am
Acad Dermatol 1990;22:1061-7.
3. Kishimoto M, Lee MJ, Mor A, Abeles AM, Solomon G, Pillinger
MH. Syphilis mimicking Reiters syndrome in an HIV-positive
patient. Am J Med Sci 2006;332:90-2.
4. Shinkuma S, Abe R, Nishimura M, Natsuga K, Fujita Y, Nomura T,
et al. Secondary syphilis mimicking warts in an HIV-positive
patient. Sex Transm Infect 2009;85:484.
5. Lewin G. Clavi syphilitici. Archiv f
ur Dermatologie und Syphilis
1893;25(1):3-34.
http://dx.doi.org/10.1016/j.jaad.2013.09.025

A case of lipoatrophy following quadrivalent

human papillomavirus vaccine administration
To the Editor: Lipoatrophy is a localized loss of
subcutaneous adipose tissue without significant
inflammation.1 Acquired forms result from physical
trauma (cold, trauma, factitious insults) or from
contact with noxious chemicals.2 It is a common
reaction at the level of injection sites and could
appear at a distant site months or years after the
injection.
Several drugs have been implicated, including
insulin and insulin analogs in diabetes, glatiramer
acetate in multiple sclerosis, corticosteroids, vasopressin, antibiotics, human growth hormone, iron
dextran, diphtheria-pertussis-tetanus immunization
serum, and antihistamines.1
We report a case of lipoatrophy that could be
associated with injection of prophylactic quadrivalent human papillomavirus vaccine Gardasil.
A 27-year-old woman presented to the dermatology clinic with a circular depression on her right
arm without any local symptoms or previous inflammation. She had no medical problems and was not
taking any medication. She reported a history of 3
intramuscular Gardasil injections on a 0-, 2-, and
6-month-schedule in the same arm, with the last
injection given 9 months before the appearance of
the lesion. The patient denied any other injection
( foreign body or steroids) or trauma to the involved
arm. Physical examination revealed a soft, nontender, 8- 3 5-cm skin depression. The patient also