i recently enjoyed the interactive case on the new england journal of medicine website, entitled, “a lump in the neck.” the co-authors include my former colleagues from the brigham, amanda westlake and jen johnson.
spoiler alert: i’m going to discuss the case below.
a few thoughts:
the patient is 44 years old and has hiv with a good cd4 count and a neck mass. the differential diagnosis is appropriate (tb versus cancer), but i wonder why the diagnosis of syphilis was delayed? how often does this occur? probably because we forget the classic tenet of medicine, that syphilis is the “great imitator.”
i basically approach my patients with hiv with the expectation that they have undiagnosed syphilis, and my challenge is to prove that they don’t have it.
for example, any patient with hiv and any neurologic signs/ symptoms, unexplained rashes, ulcers, masses, lymphadenopathy, or eye or ear complaints, i assume to be syphilis until proven otherwise. i examine the patient, reassure them that if this is syphilis it is totally curable, and send serologic tests.
see a couple of slides i have pasted below.
what do you think about syphilis in the context of hiv?
best regards, philip lederer
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