development of BP, followed by ES events toward5

the scrotum and violet-brown macular plaques werepresent in the perianal region.

A biopsy specimen of a palmar lesion demon-strated hyperkeratosis and a dermal polymorphicinfiltrate with histiocytes, plasma cells, and lympho-cytes. Warthin-Starry stain did not demonstratemicroorganisms, but polymerase chain reaction waspositive for Treponema pallidum in the skin lesionsample. Histologic examination of the perianal le-sionswas consistentwith the diagnosis of condylomaacuminata. Routine laboratory tests were normal andtests for hepatitis A, B, and Cwere negative. HIV viralload was 50,990 copies/mL and CD4 cell count was308 cell/mm3 (normal range: 500-1000 cells/mm3).A positive Venereal Disease Research Laboratorytest (titer 1:32) and a reactive Treponemapallidum particle agglutination assay were obtained,supporting the diagnosis of secondary syphilis.

Treatment was performed with a single intramus-

J AM ACAD DERMATOLVOLUME 70, NUMBER 6

Letters e131intracytoplasmic domain of BP180 and BP230. Ourcase showed IgG and IgA reactivity with variousextracellular domains of BP180, without reactivitywith 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 TakashiHashimoto, MD,c,d and Hiroyuki Okamoto,MD, PhDa

Department of Dermatologya and Department ofPediatric,b Kansai Medical University, Hirakata;Department of Dermatology,c Kurume UniversitySchool of Medicine, and Kurume UniversityInstitute of Cutaneous Cell Biology,d Japan

Funding sources: None.

Conflicts of interest: None declared.

Correspondence to: Manabu Osawa, MD, Depart-ment of Dermatology, Kansai Medical University,15-10, Sonoda-Cho, Moriguchi, Osaka, Japan570-8507

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 autoanti-

bodies 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 ofsyphilis

To the Editor: The clinical manifestations of syphilis,significant study in this field has been reported forautoimmune bullous diseases.

IgG recognition of extracellular domains of BP180was also reported to be an early and crucial event inoften described as the great imitator, are varied andmay be neglected or confused with other diseases.1Furthermore, in patients with human immunodefi-ciency virus (HIV), infections often exhibit unusualfeatures.2

A 24-year-old manwas referred to our departmentfor a 6-month history of warty lesions on the palmsand soles, unresponsive to keratolytic treatment. Hereported having sex with men, 3 sexual partnersduring the past year, and inconsistent condom use.Latent syphilis andHIV infection had been diagnosed4 years earlier after screening analysis and, at thattime, he was appropriately treated with penicillin.

Clinical examination revealed well-demarcatedhyperkeratotic plaques and some erythematousmacules and papules on the palms and on the soles(Fig 1). Exudative pink papules were observed on

Fig 1. Clavi syphilitici. Palmar hyperkeratotic plaques anderythematous papules.cular dose of benzathine penicillin (2,400,000 U).Rapid regression of palmoplantar and scrotal lesions

contact with noxious chemicals.2 It is a common

J AM ACAD DERMATOLJUNE 2014

e132 Letterswas observed after the penicillin treatment (Fig 2).The patient underwent proctologic examination,which showed no further alterations in addition toperianal condyloma acuminata, and cryosurgery ofthose lesions was performed.

The multiple and atypical manifestations ofsecondary syphilis in patients with HIV may resultin a misdiagnosis and inappropriate treatment.

In the literature, there are few reports of palmarand plantar hyperkeratotic lesions of secondarysyphilis,3,4 some of which can mimic and beconfused with viral warts or calluses, classicallyknown as clavi syphilitici.5

In the described case, the combination ofpalmar-plantar lesions, detection of Treponemapallidum by molecular biology, positive serologyfor syphilis, and rapid response to treatment withpenicillin was consistent with a diagnosis of sec-ondary syphilis.

We present this case to illustrate a rare andpotentially confounding clinical manifestation ofsyphilis, a disease that is still very present in medicalpractice. We also intend to emphasize that theacquisition of another sexually transmitted infection

Fig 2. Clavi syphilitici. Clinical appearance of palmarlesions 1 month after penicillin treatment.(STI) by a patient with HIV is a public health problembecause it means the maintenance of risk behaviorsthat enhance the transmission of these diseases. Forthe patient, the infection with an STI is a risk factorfor other STIs, so in individuals with HIV, syphilisshould be included in the differential diagnosis ofnew skin and mucosal lesions or those unresponsiveto 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 ofMedicine,b University of Porto, Portugal

Funding sources: None.

mation. She had no medical problems and was not

taking any medication. She reported a history of 3intramuscular Gardasil injections on a 0-, 2-, and6-month-schedule in the same arm, with the lastinjection given 9 months before the appearance ofthe lesion. The patient denied any other injection( foreign body or steroids) or trauma to the involvedreaction at the level of injection sites and couldappear at a distant site months or years after theinjection.

Several drugs have been implicated, includinginsulin and insulin analogs in diabetes, glatirameracetate in multiple sclerosis, corticosteroids, vaso-pressin, antibiotics, human growth hormone, irondextran, diphtheria-pertussis-tetanus immunizationserum, and antihistamines.1

We report a case of lipoatrophy that could beassociated with injection of prophylactic quadriva-lent human papillomavirus vaccine Gardasil.

A 27-year-old woman presented to the derma-tology clinic with a circular depression on her rightarm without any local symptoms or previous inflam-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

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 fur Dermatologie und Syphilis

1893;25(1):3-34.

http://dx.doi.org/10.1016/j.jaad.2013.09.025

A case of lipoatrophy following quadrivalenthuman papillomavirus vaccine administration

To the Editor: Lipoatrophy is a localized loss ofsubcutaneous adipose tissue without significantinflammation.1 Acquired forms result from physicaltrauma (cold, trauma, factitious insults) or fromarm. Physical examination revealed a soft, non-tender, 8- 3 5-cm skin depression. The patient also

Clavi syphilitician unusual presentation of syphilisReferences