28635 New onset exanthem in a 32-year-old with Hodgkin’s lymphoma

Abstract

A 32-year-old male with classic Hodgkin’s lymphoma presented to our service with a new onset exanthem, fever, weakness, and sweats. Two months prior the patient was started on brentuximab/AVD (doxorubicin, vinblastine, dacarbazine). The onset of the rash was five days after his third cycle. On the trunk and face he showed multiple erythematous papules. Histology revealed lichenoid interface and perivascular lymphocytic and histiocytic dermatitis with vasculopathic alterations. Microbiologic stains were negative (PASD, GMS, gram, Fite, Toxo, CMV) and ruled out hematoproliferative infiltration. On review of clinical history, the patient was noted to be taking oral Truvada for pre-exposure prohylaxis (PrEP) of HIV, and had recent unprotected sexual partners. Infectious serologies for HIV, Hep B/C, and syphilis, which had been negative four months prior, were repeated. RPR was positive (1:64) and FTA-Abs reactive in serum. Since the patient described headaches, vision changes, and lancinating pain radiating through the arm, there was concern for CNS involvement of Treponema pallidum. CSF examination revealed elevated WBC and protein consistent with tertiary neurosyphilis. The patient was started on intravenous crystalline penicillin treatment over 14 days. Syphilis cases have been on the rise, disproportionately affecting men who have sex with men (MSM). In the immunocompromised, syphilis can progress to the manifestation of neurosyphilis if untreated. This case emphasizes the importance of serologic testing, especially in immunocompromised patients and raises awareness of the progression to complicated Treponema infections in patients receiving immunosuppressive medication.