What is the treatment approach for an HIV (Human Immunodeficiency Virus) positive patient with latent syphilis presenting with nodular swellings over the face and body?

Treatment of Nodular Syphilis in HIV-Positive Patients

Treat this HIV-positive patient with nodular swellings as secondary syphilis using benzathine penicillin G 2.4 million units IM as a single dose, which is the standard CDC-recommended regimen for early syphilis regardless of HIV status. 1, 2

Clinical Recognition

The nodular presentation strongly suggests secondary syphilis with granulomatous dermatitis, an uncommon but well-documented variant that occurs more frequently in HIV-positive patients. 3, 4

• Nodular secondary syphilis manifests as skin-colored to erythematous nodules that can be disseminated across the face, trunk, and extremities 4
• HIV coinfection increases the likelihood of atypical syphilitic presentations, including more apparent clinical lesions and potentially accelerated disease progression 5
• The nodular variant can be confused with other conditions (erythema nodosum, cutaneous lymphomas, vasculitis), making biopsy essential for confirmation 3, 6

Diagnostic Confirmation Required

Before initiating treatment, confirm the diagnosis through:

• Serologic testing: Both nontreponemal (RPR or VDRL) and treponemal tests (FTA-ABS or TP-PA) 1
• Skin biopsy: Should demonstrate granulomatous dermatitis with plasma cells, lymphocytes, and histiocytes; treponemal immunostaining can highlight spirochetes in the dermis 7, 3, 4
• HIV testing confirmation: If not already documented, as all syphilis patients should be tested for HIV 1

Treatment Protocol

For secondary syphilis (which includes nodular presentations):

• First-line: Benzathine penicillin G 2.4 million units IM in a single dose 1, 2
• Penicillin-allergic patients: Doxycycline 100 mg orally twice daily for 14 days 1, 2
• The treatment regimen is identical for HIV-positive and HIV-negative patients with early syphilis 2

Critical caveat: The patient is described as having "latent syphilis," but nodular swellings indicate active secondary disease, not latent infection. Latent syphilis by definition has no clinical manifestations. 5, 1 This distinction is crucial because it determines treatment duration.

Neurosyphilis Evaluation

Given HIV coinfection, consider CSF examination if any of the following are present:

• Neurological signs or symptoms (headache, altered mental status, cranial nerve deficits) 1, 2
• Ocular or auditory symptoms 2
• Treatment failure or very high RPR titers (though specific cutoffs are not universally defined) 2
• If neurosyphilis is confirmed, treatment changes to aqueous crystalline penicillin G 18-24 million units IV daily for 10-14 days 1, 2

HIV-Specific Considerations

• HIV-positive patients may experience more rapid progression and more florid cutaneous manifestations 5
• Early syphilis treatment can cause transient decreases in CD4+ count and increases in HIV viral load, which typically improve after treatment 5
• Closer follow-up is mandatory in HIV-positive patients to detect potential treatment failure 2
• Despite theoretical concerns, current evidence shows no benefit to multiple doses of benzathine penicillin for early syphilis in HIV-infected patients compared to the standard single dose 2

Jarisch-Herxheimer Reaction Warning

• Counsel the patient that an acute febrile reaction with headache, myalgia, and worsening of skin lesions may occur within 24 hours of treatment 1, 2
• This reaction is more common in early syphilis and does not indicate treatment failure 2
• Supportive care with antipyretics is appropriate 1

Follow-Up Monitoring

• Repeat quantitative nontreponemal tests (RPR or VDRL) at 3,6,12, and 24 months 1, 2
• Expected response: A fourfold decline in titer within 6 months for secondary syphilis 1, 2
• Treatment failure: Defined as failure of nontreponemal titers to decline fourfold within 6 months 1, 2
• If treatment failure occurs, re-evaluate for HIV status (if not already known), perform CSF examination, and consider retreatment 2
• Use the same testing method (either RPR or VDRL, not both) throughout follow-up, as results cannot be directly compared 2

Partner Management

• All sexual partners exposed within 90 days before diagnosis should be treated presumptively, even if seronegative 2
• Partners exposed more than 90 days before diagnosis should be treated presumptively if serologic results are not immediately available and follow-up is uncertain 2