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Paper text:
the prozone effect is most often associated with secondary syphilis , human immunodeficiency virus ( hiv ) co - infection , and pregnancy .
the incidence of the prozone phenomenon is attaining clinical significance due to increasing population at risk for sexually transmitted diseases , especially those who are hiv positive .
a 36-year - old female presented with a chief complaint of rash all over the body , of 15 days duration , associated with severe itching . on detailed history elicitation ,
the patient applied some native medications and developed generalized itching and presented with a picture of contact irritant dermatitis in the form of papules , vesicles , and scaling , all over the body .
the patient was treated for the same with a combination of topical steroids and antihistamines .
the patient 's rash was persistent in the form of macules , papules , and scaling .
a thorough examination revealed the presence of few lesions on the genitalia mainly on the labia majora [ figure 1a ] , which were flat topped papules and the patient also had a mucous patch over the hard palate [ figure 2a ] .
thus , secondary syphilis was strongly suspected and the patient was subjected for venereal disease research laboratory ( vdrl ) testing .
as the suspicion of secondary syphilis was high , we conducted a detailed examination of the patient 's husband .
he denied a history of any sexual exposure and any genital lesion , but gave a history of intermittent urethral discharge .
therefore , we requested for repeat vdrl test , with higher dilution and it was reactive with 1 : 512 dilution .
the patient and husband were subjected to hiv testing , and both were found to be seropositive .
all skin , oral [ figure 2b ] lesions regressed and condyloma lesions [ figure 1b ] disappeared after one month of follow - up .
the patients were referred to the voluntary counseling and testing center ( vctc ) for further evaluation and initiation of antiretroviral therapy .
genital lesions  before treatment oral lesions  before treatment oral lesions  after treatment disappearance of lesions after treatment
prozone phenomenon is an immunological event , relying on an antigen - antibody interaction such as in rapid plasma reagin ( rpr ) or vdrl .
an agglutination or precipitation reaction will be positive ( i.e. , visible through lattice formation ) depending on several factors that determine the size and solubility of the immune complex formed in vitro .
the optimal ratio of the antigen antibody yields an insoluble precipitate that is visible , thus rendering the test positive .
the zone of equivalence defines this optimal ratio . in the zone of the antibody excess ( prozone ) or antigen excess ( post zone ) , false negative results will occur .
the prozone phenomenon in the setting of syphilis may become prevalent because of the current acquired immunodeficiency syndrome ( aids ) epidemic . as syphilis and hiv mutually increase the chance of contracting other diseases , anomalous b - cell behavior can lead to hyper - responsiveness to antigenic stimulation , leading to excess antibody production .
this is performed by diluting the patient 's serum to bring the antibody concentration into the zone of equivalence .
therefore , it is important to notify the laboratory in this regard , when the clinical findings strongly suggest syphilis and when the nontreponemal serological test results are negative .
the purpose of this article is to focus attention on the prozone phenomenon in the setting of syphilis , which may become more prevalent due to increasing hiv incidence .
thus , an astute dermatologist who maintains a high index of suspicion and continued familiarity with protean manifestations of secondary syphilis should look for the prozone phenomenon in suspected cases .
prozone phenomenon is a false negative response resulting from high antibody titer which interferes with formation of antigen- antibody lattice , necessary to visualize a positive flocculation test . 
 we present a case of secondary syphilis who presented to us with features of contact irritant dermatitis . 
 she initially tested non- reactive for vdrl testing but tested positive with higher dilution . 
 the prozone phenomenon is attaining importance because of increasing prevalence of acquired immune deficiency syndrome . 
 so one needs to be familiar with the occurrence of prozone phenomenon .