<![CDATA[Secondary syphilis, notoriously known as "the great imitator," can present with highly atypical cutaneous manifestations, particularly in immunocompromised individuals. In patients with human immunodeficiency virus (HIV) co-infection, distinguishing secondary syphilis from HIV-associated dermatoses, such as pruritic papular eruption (PPE), poses a significant diagnostic challenge. This report aims to describe an atypical case of secondary syphilis mimicking PPE in a newly diagnosed HIV patient, to highlight the diagnostic complexities and the potential risks of inappropriate empiric systemic corticosteroid therapy. A 26-year-old male presented with a one-month history of a generalized, intensely pruritic, and crusted papular rash. His condition rapidly disseminated and worsened following empiric treatment with systemic corticosteroids by a general practitioner. Dermatological examination revealed generalized, well-demarcated erythematous papules with overlying crusts and fine scales, closely mimicking PPE. The patient reported a history of high-risk sexual behavior. Serological testing confirmed active secondary syphilis (VDRL 1:64, TPHA reactive) and revealed a previously undiagnosed HIV infection. The patient was successfully treated with a single dose of intramuscular benzathine penicillin G (2.4 million IU) and topical therapy comprising desoximetasone 0.25% and gentamicin 0.1% creams, alongside an immediate referral for antiretroviral therapy (ART). This case highlights the clinical overlap between atypical secondary syphilis and PPE in HIV-positive patients. It strongly underscores the critical need for comprehensive sexually transmitted infection (STI) screening prior to initiating systemic immunosuppressive therapy for generalized eruptions, especially in high-risk populations. ]]>
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