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• 49 yo man • HIV positive 16 yrs. ago• CD4 15 on diagnosis

• Disseminated cutaneous Kaposi’s Sarcoma

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Initiated AZT/3TC/EFAVIRENZ

• Disseminated cutaneous Kaposi’s Sarcoma slowed then faded over the subsequent 18 months

2006 CD4 510/21% HIV Viral Load<50

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Eventually Switched to TDF/FTC/EFAVIRENZ

2014 CD4 520/28% HIV Viral Load ND

• Developed recurrent headaches over last few months

• CT brain done revealed no intracranial abnormalities/lesions

however there were several lytic lesions in the skull…largest 1.5 x

1.5 cm

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Bone scan revealed that 3 of these skull lesions had low grade uptake/activity along with subtle small Rt mid humeral and left distal femur lesions (no x-ray correlate with these extremity findings)

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Referred for further workup:

Headaches now better but still present intermittently…also tinnitus and slight Rt sided decreased hearing mentioned as a matter of fact

Physical examination was unremarkable

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Bloods all unremarkable including calcium/PSA/serum and urine immunoelectrophoresis etc.

CT scan of chest/abdo and MRI of brain pending

Any other investigations?

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Serum VDRL was 1:128 and was negative in March 2013…denies sexual activity of any sort

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LP done revealed increased WBCs, elevated protein and positive VDRL

Treated with iv Penicillin x 2 weeks

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Are bone lesions related to syphilis????

Role of repeat bone scan post CNS syphilis therapy if scans of chest/abdo negative?

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September 2014

• CT chest and abdo/pelvis normal

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November 2014

• Repeat bone scan revealed all areas of tracer uptake improved as c/w summer 2014 but a new area of uptake noted in Rt anterior 5th rib

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November 2014

• Rt rib lesion was coincident with trauma as he had fallen at work and hurt this exact area

• VDRL down to 1:8

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January 2015

• Repeat MRI skull revealed disappearance of all calvarial lesions seen in summer 2014

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March 2015

• Repeat bone scan normal

• Feeling back to normal with no headaches/normal hearing and no tinnitus