A 26-year-old HIV-positive, homosexual,
Black male presented to his
nurse practitioner (NP) for his quarterly
HIV follow-up exam. During the
review of systems, the patient reported
having a long-standing tender rash on
his right hand. The rash was evaluated
at a previous visit and he was given an
antimicrobial ointment that was ineffective.
The rash continued to enlarge
and became pruritic. Visual exam of
the right palm revealed a single hyperpigmented
erythematous peeling lesion
on the thenar eminence; the lesion was
3 to 4 cm in length with an area of
raised border. The lesion closely resembled
a bite mark. Two 0.5- to 1 cm
diameter satellite lesions with a similar
appearance were present on his right
palm near the base of the index and
little fi ngers. The patient’s history
included three documented episodes of
syphilis.