A 35–year–old bisexual African–American male presented with complaints of a rapidly progressing rash over 2 weeks associated with fatigue. The rash began on his palms, but later appeared on his soles. He denied any pruritus, pain or discharge associated with the rash. He also denied any symptoms of dysuria, arthralgias or eye irritation. The patient had no childhood or past medical history. His social history included multiple sexual partners with occasional use of barrier protection. There was no family history of dermatologic or autoimmune diseases. Upon examination, the rash appeared as psoriaform hyperkeratotic plaques on the palms and soles. The borders of the rash were noted to have desquamating skin (Figure 1). There was also subungual hyperkeratosis and thickening of the nail plate. No other rashes were noted. Given the sexual history and rapidity of the symptoms, an HIV and syphilis test w ere performed. Notable labs included positive HIV assay with an absolute CD4 count of 6 and a viral load over 750,000 copies and a negative RPR. The rash was diagnosed as keratoderma blennorrhagica and the patient was diagnosed with AIDS. No further diagnostic tests were performed. He was started on oral Acitretin and systemic corticosteroids for the rash. He showed significant improvement and was later discharged home with infectious disease follow–up for treatment of AIDS.
AIDS is characterized by immune dysregulation and depletion of CD4+ T cells and increased vulnerability to different pathological conditions, including dermatoses. Reactive arthritis has been reported in patients with HIV infection. Extra–articular involvement in reactive arthritis is associated with a variety of manifestations including rashes such as Keratoderma blennorrhagica.
Timely appropriate diagnostic testing should be performed as Keratoderma blennorrhagica is associated with a variety of sexually transmitted or gastrointestinal diseases. Our patient presented only with the rapidly developing rash on his palms and soles without other joint, urinary, vision or gastrointestinal symptoms.
Figure 1An HIV–seropositive man with acute (2 week) evolution of a markedly thickened hyperkeratotic lesion in the palms, soles and scalp with micaceous scale.