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Endgames Case Report

Dizziness and rash in an HIV positive man

BMJ 2012; 344 doi: (Published 28 June 2012) Cite this as: BMJ 2012;344:e4167
  1. Daniel Bradshaw, specialist registrar,
  2. Nneka Nwokolo, consultant physician
  1. 1Chelsea and Westminster Hospital, London SW10 9NH, UK
  1. Correspondence to: D Bradshaw dan.bradshaw{at}

A 32 year old homosexual Indian man who was positive for HIV (CD4 cell count 416×106/L, HIV-1 RNA 64 000 copies/mL) presented to his HIV doctor with a two month history of dizziness and 7 kg weight loss. He felt unsteady on walking but denied true vertigo, falls, visual disturbance, or loss of consciousness. He reported loss of eyebrow hair and an itchy rash. HIV-1 positivity had been identified four years previously, but he had not had any HIV related illnesses and took no drugs. He had not received antiretroviral drugs because his CD4 cell count was greater than the 350×106/L threshold below which current UK guidelines recommend treatment for HIV.1 Examination showed an ataxic gait with negative rombergism, but otherwise normal neurology. A generalised scaly maculopapular eruption including the palms, soles, and genitalia and loss of eyebrow hair were seen. Three irregular ulcers were visible on the hard palate.


  • 1 What is the likely diagnosis for a patient with this history and these findings?

  • 2 What investigations would you request?

  • 3 How would you manage this patient?

  • 4 What factors should be considered in the follow-up of this patient?


1 What is the likely diagnosis for a patient with this history and these findings?

Short answer

Secondary syphilis with neurological involvement.

Long answer

The most likely diagnosis is secondary syphilis with neurological involvement. Guttate psoriasis may mimic the rash of secondary syphilis and is more common in HIV infection, but it would not cause abnormal neurology or systemic symptoms. Mycosis fungoides and leprosy are rarer causes of a similar rash. Primary toxoplasmosis and viral infections (for example, infection with cytomegalovirus and Epstein-Barr virus) may cause systemic illness and rash, but …

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