Picture of the month-quiz case. Early congenital syphilis.

A 2-MONTH-OLD BOY WAS ADMITTED TO OUR hospital because of a 4-day history of fever, cough, purulent nasal discharge, and skin lesions. The patient had been born via spontaneous vaginal delivery at 39 weeks’ gestation, and he was apparently normal at birth, excluding low weight (2500 kg). However, his mother had not received any prenatal care; therefore, a maternal laboratory evaluation was carried out just before delivery. Her serologic results for hepatitis B and hepatitis C, toxoplasma, and the rapid plasma reagin (RPR) test for syphilis were negative, but serology for human immunodeficiency virus (HIV) was positive. This maternal HIV infection was not previously known. Diagnosis of HIV in the neonate was then confirmed by DNA detection (polymerase chain reaction), and antiretroviral treatment was started. Physical examination revealed a blood-tinged nasal discharge, upper respiratory tract noises, and palpable hepatosplenomegaly. Erythematous to copper-red macules and papules were distributed over the trunk and extremities, including the palms and soles (Figure 1). Many lesions had peripheral or concentric desquamation. Fissures were seen on the lips (Figure 2). Laboratory investigation showed anemia (hemoglobin, 7.1 g/dL [to convert to grams per liter, multiply by 10.0]; reference range, 14-18 g/dL; and hematocrit, 20.7% [to convert to proportion of 1.0, multiply by 0.01]; reference range, 42-52%), and some schistocytes were seen in the peripheral blood smear. Platelet count was normal. Results from a Coombs test were negative. The results from the patient’s liver and renal function tests were normal. A chest radiography showed no alterations. A skin biopsy was taken from a lesion on the leg. What is your diagnosis? Author Affiliations: Departments of Dermatology (Drs Rodriguez-Caruncho, Fuente, Bielsa, and Ferrándiz), Pathology (Dr Fernandez-Figueras), and Pediatrics (Dr Rodrigo), Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.