A 46-year-old man presented with a rash over his trunk, neck and limbs. A viral exanthem was suspected and an initial diagnosis of acute cytomegalovirus (CMV) infection was made on the basis of serology results (positive IgM, no quantitation indicated, and negative IgG). Additional laboratory tests showed an elevated C-reactive protein level (26 mg/L; reference interval [RI], 0e10 mg/L) and erythrocyte sedimentation rate (26 mm/h; RI, < 20 mm/h), and normal routine haematology and biochemistry results, apart from a slight elevation of the globulin level (45 g/L; RI, 20e40 g/L). However, the rash persisted, the patient noticed hair loss and he developed worsening visual impairment, which prompted an urgent ophthalmology referral 4 months after initial presentation. On ophthalmological review, the patient was noted to have decreased visual acuity bilaterally (right eye, 6/15; left eye, 6/24) and right optic disc swelling. Syphilis serology was subsequently performed and the results (Treponema pallidum particle agglutination [TPPA] positive and rapid plasma reagin [RPR] reactive [1 : 32]) prompted referral to the infectious diseases unit.Clinical examination at presentation to the infectious diseases unit revealed widespread symmetrical erythematous papulosquamous plaques over his trunk, neck and limbs (Box 1), with several small plaques on the plantar aspect of his left hand and left foot. He also had patchy alopecia (Box 2) and bilateral inguinal lymphadenopathy. At this time, the patient also reported unprotected intercourse with casual male partners. His HIV test result was negative and he had not been tested for syphilis previously. Retrospective testing of the earlier serum positive for CMV IgM revealed positive TPPA and reactive RPR (1 : 64). A punch biopsy of the rash showed a plasma cell-rich granulomatous process spanning the dermis, which supported the diagnosis of syphilis, likely consistent with tertiary syphilis. He was treated with a 15-day course of intravenous benzylpenicillin with concomitant prednisolone in the first 36 hours (given the optic involvement) to reduce the likelihood of a JarischeHerxheimer reaction. Over the treatment course, the patient remained well and his rash started to settle. On follow-up 3 months after treatment, his alopecia had completely resolved and his rash had significantly improved. u 1 Erythematous papulo-squamous plaques over the trunk and arms of the patient 2 Patchy alopecia: note the irregular thinned ("moth-eaten") patches of hair loss characteristic of syphilis T his case exemplifies the consequences of diagnosis based on the performance of a test, which may not have been indicated from the clinical presentation, compounded by a false-positive laboratory result. First, the presentation was not typical of CMV infection. In immunocompetent adults, the most common clinical presentation of CMV infection is a self-limiting mononucleosis-like syndrome 1 characterised by fevers and malaise. Predominant skin manifestations are rare in CMV infection in immunocompetent pa...
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