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A lip ulcer as a first sign of early syphilis in a patient with unknown HIV infection: a case report. Pozo Porta 1 , I. Iriarte Ortabe 2 , P. Zaballos Diego 4 , M. Morey Mas 2 , J. Pastor Fortea 1 , I. Forteza-Rey Borralleras 3. Hospital Universitario Son Dureta. Correspondencia: A. E-mail: albertpozoporta hotmail. This should therefore be taken into account with regard to oral lesions, as the oral cavity is the first extragenital location in Treponema pallidum infection, together with the possibility of atypical manifestations, given that infection by the HIV virus can affect the natural course of syphilis and even the response to treatment. The case presented is aimed at highlighting the diagnosis of Treponema pallidum infection based on a lip lesion and how this should serve as a sign for further study in order to confirm the secondary diagnosis of HIV infection. It shows the importance of a differential diagnosis of this lesion that includes squamous cell carcinoma of the lip and herpes infection. A year-old male was sent to the Emergency Unit by his doctor for an evaluation of a lesion on his lower lip that had been evolving for a month and a half. His personal background included: undetermined hepatitis, a tonsillectomy during his youth, and a homosexual habit. For a month and a half the patient had noticed the appearance of a lesion on his lower lip that had improved partially with the acyclovir treatment prescribed by his GP, but that worsened on stopping it. The patient also referred to lesions on the scrotum and left foot that had appeared recently. The physical examination revealed an ulcerated lesion measuring 2 cm on the left side of the lower lip vermilion, with an indurated base, that was not painful to palpation Fig. There were no neck adenopathies and the intraoral examination was negative. No other lesions were observed in the area of the head and neck. He had a simultaneous interdigital lesion on the left foot with an ulcerous appearance that measured 0. It had a smooth surface, a serous exudate and there were numerous smaller sized macules on the sole of the same foot that were round and copper colored and painless to palpation Fig. Lastly, he had on his scrotum various small lesions measuring less than 0. The remaining physical examination was within normal limits. TPHA; Positive. A complementary CSF study was not carried out given the absence of neurological symptoms and the short development period. As the diagnosis was of syphilis in a patient that was carrying HIV, the treatment consisted in penicillin benzathine 2. The serologic tests at 6 months confirmed the resolution of the symptoms. Syphilis or lues is a chronic systemic infection found worldwide that is transmitted through sexual contact. It is caused by a spirochete called Treponema pallidum TP , 1,2 which is a slender spiral organism with a width of 0. It can be identified by its characteristic morphology and motility when observed by dark field microscopy or with fluorescence techniques. It does not grow in a laboratory medium, and it rarely reproduces itself in tissue cultures, nor will it survive for long outside the human body. It penetrates through mucosa and skin reaching the regional lymphatic nodes in a few hours, spreading through the organism rapidly. Following the epidemics over the last few decades in conjunction with the so called «sexual revolution» from the end on the 80s and during the 90s the incidence of primary and secondary syphilis doubled in black Americans due to cocaine abuse and prostitution. At the end of the nineties a decrease in the syphilis trend was observed due generally to a modification in sexual conduct as a result of the appearance of the HIV virus and to the intensive measures adopted by the public health services. Syphilis left to develop freely has three clearly distinguishable stages. In the primary stage primary syphilis the clinical presentation consists in the appearance of a chancre, regional adenopathy and general symptoms of discomfort due to the dissemination of the Treponema from the inoculation area into the blood stream. In the secondary stage secondary syphilis a new constitutional set of symptoms appear. The nodes are affected generally and disseminated cutaneous sores known as syphilids appear. These can be of two types: macules that appear earlier on or papules that, being located on the palms or soles, are the most characteristic lesion during this period. Finally, in the tertiary stage the body is affected generally and any organ may be affected. During this period, among the symptoms that appear are the characteristic gummas and nervous system disorders. Orally syphilis produces a chancre red papule that quickly turns into a painful ulcer with a serum-sanguinolent scab , mucosal patches, gummas and associated adenopathies. In patients with intercurrent HIV infection, these stages are not quite so clearly distinguishable as they overlap and the clinical presentation will be altered. In the case of syphilis, the oral cavity is the first extragenital location. With regard to the case in this article, and in view of the lip lesion that led the patient to seek consultation with our service, the differential diagnosis was made, after ruling out the initial diagnosis of a lip ulcer due to herpes as the infection was so florid , of either a lesion of a carcinoma type or what turned out to be, syphilis of the lip, that required nonsurgical treatment. We should emphasize that due to the initial diagnosis of a sexually transmitted disease, studies leading to the second diagnosis of HIV seropositivity were considered that permitted prior anti-retroviral treatment. The usual diagnostic techniques for syphilis are divided into those that are direct, and based on the visualization of the spirochete under the microscope, and those that are indirect or serological techniques. These in turn are differentiated into non-treponemal or reaginic RPR rapid plasma reagin VDRL venereal disease research laboratory , that are the most used, and which measure antibodies to the substances produced by damaged tissue, and treponemal tests such as FTAABS fluorescent treponemal antibody absortion and also TPHA Treponema Pallidum hemaglutination assay that assess the existence of antibodies to TP. Thus, P. Both types of serological tests tend to be carried out together using serum, plasma or CSF depending on the staging or on the suspicions as to how affected the patient is. With regard to the diagnosis of syphilis in patients infected by HIV, this can be more complicated due to false serological reactions and to the atypical presentation of lues when there is HIV infection. The treatment required for syphilis depends of the stage of the disease. Penicillin is the drug of choice for all stages of syphilis. In order to cure syphilis, a plasma level of at least 0. During early staging, a single dose of 2. In late syphilis cases that have been evolving for over a year or of unknown duration, the same dose is recommended but repeated once a week for a period of three weeks. Finally, for the treatment of neurosyphilis, endovenous treatment should be included prior to these last doses. A greater failure rate in syphilis treatment has been observed in HIV positive patients, 13,27,28 however, the classical guidelines are considered useful for initial treatment. Lastly, clinical and serological checks every few months for a year, or for two if the disease is more advanced is essential. Also essential is the identification of any sexual contact the patient has had three months previously in early syphilis cases, and for a year in those cases that are more advanced. Barcelona: Ediciones Doyma; ;p. Barcelona: Editorial Salvat; ;p. Centers for Disease Control and Prevention. Continuing increase of infectious syphilis: United States. Syphilis and HIV infection. J Infect Dis ; The association of syphilis with risk of human immunodeficiency virus infection in patients attending sexually transmitted disease clinics. Arch Intern Med ; Characteristics of patients with syphilis attending Baltimore STD clinics. Multiple high-risk subgroups and interactions with human immunodeficiency virus infection. Arch Intern Med ; Human immunodeficiency virus infection among men with sexually transmitted diseases. N Engl J Med ; Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection. Ann Intern Med ; Effect of human immunodeficiency virus HIV infection on the course of syphilis and on the response to treatment. Unusual manifestations of secondary syphilis and abnormal humoral immune response to Treponema pallidum antigens in a homosexual man with asymptomatic human immunodeficiency virus infection. J Am Acad Dermatol ; Sands M, Markus A. Lues maligna, or ulceronodular syphilis, in a man infected with human immunodeficiency virus: case report and review. Clin Infect Dis ; Oral presentation of secondary syphilis. Br Dent J ; Specific syphilis serological tests may become negative in HIV infection. AIDS ; Syphilis treatment response in HIV-infected individuals. AIDS ; Servicios Personalizados Revista. Forteza-Rey Borralleras 3 Abstract : A case report is presented of a patient with a lip ulcer that led to a primary diagnosis of infection through Treponema pallidum and to a secondary diagnosis of HIV seropositivity. The diagnosis was made by serology and the antibiotic treatment was effective for the syphilis. We conclude that when faced by a lesion of the lip that has an ulcerous appearance, a differential diagnosis should be contemplated that includes a syphilis chancre and, if this is confirmed, the necessary complementary test should be carried out in order to rule out concomitant HIV infection. Case Report A year-old male was sent to the Emergency Unit by his doctor for an evaluation of a lesion on his lower lip that had been evolving for a month and a half. Discussion Syphilis or lues is a chronic systemic infection found worldwide that is transmitted through sexual contact. Abstract : A case report is presented of a patient with a lip ulcer that led to a primary diagnosis of infection through Treponema pallidum and to a secondary diagnosis of HIV seropositivity.