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A 36-year-old man presented to the emergency department with 3 weeks of generalized weakness and a dry cough. He reported hair loss for 1 month. Medical history was significant for opioid and alcohol use disorders, injection drug use, and chronic HIV infection. He discontinued his antiretroviral therapy 2 years prior to presentation. At that time, his CD4+ cell count was 820/μL and his HIV viral load was undetectable.
On presentation, his heart rate was 88/min and regular; blood pressure, 90/58 mm Hg; oxygen saturation, 100% on room air; and respiratory rate, 20/min. He was afebrile. Cardiorespiratory auscultation was deferred because a diagnosis of COVID-19 was considered. He had a faint maculopapular rash on his arms and torso and patchy hair loss on his scalp (Figure). There were no genital lesions or mucosal ulcerations.
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“Moth-eaten” alopecia caused by secondary syphilis
B. Check rapid plasma reagin (RPR) level
The key to the correct diagnosis was the “moth-eaten” pattern of hair loss associated with a faint maculopapular rash. These findings in the setting of chronic HIV infection suggested a diagnosis of secondary syphilis. This patient did not have other features of systemic lupus erythematosus, such as a malar rash, photosensitivity, or mouth ulcerations, to support ordering an antinuclear antibody screen (choice A). Examination of skin scrapings (choice C) can diagnose tinea capitis, but tinea capitis was unlikely because the alopecia was noninflammatory based on lack of scaling or perifollicular erythema. Punch biopsy of the scalp (choice D) can diagnose alopecia areata and may demonstrate the characteristic perivascular plasmacytic infiltration of syphilis, but biopsy was considered invasive prior to performing serologic testing for syphilis.
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Corresponding Author: Wayne L. Gold, MD, Toronto General Hospital, 200 Elizabeth St, 13EN-213, Toronto, ON M5G 2C4, Canada (email@example.com).
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient for providing permission to share his information.
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