1. CASE 2 49 yo man HIV positive 16 yrs. ago CD4 15 on diagnosis Disseminated cutaneous Kaposi’s Sarcoma

2. CASE 2 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

3. CASE 2 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

4. CASE 2 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)

5. CASE 2 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

6. CASE 2 Bloods all unremarkable including calcium/PSA/serum and urine immunoelectrophoresis etc. CT scan of chest/abdo and MRI of brain pending Any other investigations?

7. CASE 2 Serum VDRL was 1:128 and was negative in March 2013…denies sexual activity of any sort

8. CASE 2 LP done revealed increased WBCs, elevated protein and positive VDRL Treated with iv Penicillin x 2 weeks

9. CASE 2 Are bone lesions related to syphilis???? Role of repeat bone scan post CNS syphilis therapy if scans of chest/abdo negative?

10. CASE 2 September 2014 CT chest and abdo/pelvis normal

11. CASE 2 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 5 th rib

12. CASE 2 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

13. CASE 2 January 2015 Repeat MRI skull revealed disappearance of all calvarial lesions seen in summer 2014

14. CASE 2 March 2015 Repeat bone scan normal Feeling back to normal with no headaches/normal hearing and no tinnitus