Six months after testing positive for HIV in 10 bands, a 24-year-old homosexual man presented with a macular rash on his palms and soles. He first noticed the lesions 2 weeks earlier; they were not pruritic or painful. He also had a brighter, more inflamed rash in the groin and antecubital fossae that was presumed to be a yeast infection and was treated with fluconazole. He had no other symptoms.
The patient had tonsillitis 2 and a half years earlier. For the past 2 years, he had been taking atomoxetine for attention deficit disorder. A few months before presentation, he complained of fatigue secondary to stress and bupropion was prescribed.
The patient's history and the clinical appearance of the rash suggested secondary syphilis. Results of a rapid plasma reagin test were positive (titer of 1:128).
The skin eruption is characteristic of secondary syphilis. Because numerous conditions are associated with macular lesions on the palms and soles—including erythema multiforme and Rocky Mountain spotted fever—syphilis is often called the "great imitator."
This patient was referred to a county health department for treatment.