A case report was compiled using information retrospectively collected from the patient’s electronic and physical medical records. Pictures were taken at different stages of the illness, with the patient’s verbal and written consent.

The patient is a 29-year-old HIV-positive female on a first-line dolutegravir (DTG)-based ART regimen. She is single and works in a clothing factory. She presented on March 23 2022, with a 2-week history of hair loss. She initially noted her braids falling off and then progressive hair loss on her scalp, eyebrows, eyelashes, axilla, and groin. There was mild associated itching with no scaling on the head. The patient was not on any new medications. She also complained of a non-itchy rash on the limbs, mainly on the hands, rough looking and brownish. She reported no contact with anyone with similar symptoms and has not been pregnant before.

On review of systems, she reported a painless pustule on the groin, which has been there for about a year, not growing, with no associated discomfort. She had not reported it before, as it was not causing any issues. She reported no other genitourinary symptoms.

The patient was diagnosed with HIV and commenced ART in 2014. She is still on first-line ART, initially initiated on TDF/3TC/EFV, and later transitioned to TDF/3TC/DTG on 30/12/2021 per HIV program recommendations, three months before presentation. Her latest laboratory results at presentation were a lower-than-detectable viral load (4/8/2021) and serum creatinine of 50 μm/L (4/8/2021).

On physical examination, the patient looked well and stable; her temperature was 36.50C, her blood pressure was 120/50mmHg, her heart rate was 80b/min, and her respiratory rate was 18c/min. She was pink, well hydrated, and had no jaundice or oedema. Her oral cavity was clear.

She had extensive scalp alopecia, with patchy areas with hair, but no scaling was noted. There was also hair loss on the eyebrows, eyelashes, axilla and groin regions (Fig. 1). She also had hyperpigmented papules on the palmar aspect of both hands extending to the wrist, also called Buschke Ollendorf sign when there is tenderness on the application of blunt pressure on the papules [11] (Fig. 2A) and asymmetrical, homogenous, clearly demarcated hypopigmentation on the anterior of both feet (Fig. 2B). On examination of her genitourinary system, she had a painless lump measuring about 0.5 cm x 0.5 cm on the left peri vulval region. There were no palpable lymph nodes in the groin on either side. Examination of her chest, cardiovascular system and abdomen were normal.

Extensive alopecia, with “moth-eaten appearance”, noted on the scalp, with patchy areas with hair. Hair loss is noted on the eyebrows.

A Hypopigmentation of the anterior half of both feet, with a mottled appearance, consistent with Leukoderma syphilliticum, also called syphilis vitiligo. B Hyperpigmented maculopapular lesions in the palms of both hands also known as Buschke Ollendorf sign.

The investigations done for the patient at presentation included a full blood count (FBC) and a syphilis determine rapid tests. The full blood count showed a haemoglobin of 10.7 g/dl, mean corpuscular volume (MCV) of 90.3 fl., a white cell count of 4.1 × 10 9cells/litre and a platelet count of 309 × 109/litre. The syphilis determine rapid test (for antibodies) was positive. The titre was not estimated due to the limited laboratory capacity.

The patient was treated with benzathine penicillin 2.4MU stat per World Health Organization (WHO) guidelines for secondary syphilis [12]. At review after two weeks, some improvement was observed in the maculopapular rash on the palms, and the genital lump had disappeared completely. However, there was no change in hair growth and skin depigmentation. The patient missed her review two weeks later and only returned after three months for her ART refill. At this visit, she was attended to by another clinician and given another three-month supply of ART medication. Since her contacts were not updated in the database, she could not be reached for further review and evaluation until September 21 2022. The patient was given three doses of benzathine penicillin at this time, and a rapid plasma reagin (RPR) titre done in October 2022 was less than 1:8.

The patient reported that hair started growing three months after treatment, and the hypopigmentation cleared earlier than the hair growth (Figs. 3, 4 and 5).

The hair, eyelashes and eyebrows grew back three months after therapy with benzathine Penicillin (pictured here six months after therapy)

(A) The maculopapular lesions disappeared from the palmar surface of both hands within two weeks. (B) The hypopigmentation on both feet cleared within three months (pictured here after six months of therapy)

Timelines in patient care from HIV diagnosis to diagnosis of syphilis and treatment

The patient had a viral load taken in August 2022, and it showed that her viral load was elevated at 13,187 copies/ml, and the CD4 count was 675 cells/microlitre. She subsequently admitted that she had struggled to take her treatment since May 2022 due to psychosocial issues. For this, she received stepped-up adherence counselling. By October 2022, she was diagnosed with drug-sensitive TB and had completed treatment. She was further referred to the cardiologist for further review and is being reviewed every six months for symptoms of relapse. In this case, we monitored variables such as RPR titers, clinical symptoms disappearance/relapse, time from treatment to recovery (disappearance of symptoms), and time to relapse, if ever relapse had to reoccur.

The patient gave written informed consent for the pictures to be taken, used for this study, and for reporting clinical details. The Eswatini Health and Human Research Review Board (EHHRB) has approved this case report’s public presentation and dissemination.