Syphilis - Final

Atypical oral manifestations
in secondary syphilis
Puneeta Vohra Singh1, Ranjit Patil2
1 Department of Oral Diagnosis, Medicine and Radiology, PDM Dental College and Research Institute, Bahadurgarh, Haryana, India
2 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, King George Medical University, Lukhnow, Uttar Pradesh, India
Singh PV, Patil R. Atypical oral manifestations in secondary syphilis. Indian J Dent Res [serial online] 2013 [cited 2019 Mar 16];24:142-4.
Available from: http://www.ijdr.in/text.asp?2013/24/1/142/114928
Case Report
• A 60-year-old unmarried Indian male reported to the Department of Oral Diagnosis Medicine and
Radiology
• with a chief complaint of bleeding from lips since 15 days.
• He also complained of fever, pain, weight loss, loss of appetite, weakness and numerous itchy
erythematous lesions on hands, forearms, back and chest since 15 days.
• The patient gave past history of similar skin lesions 2 years back, which subsided after the
treatment.
• The patient also gave history of unprotected sexual contacts with multiple commercial sex workers.
Case Report
• On general examination
• The patient was weak, cachexic, poorly nourished,
thin built with normal posture and gait.
• Extraoral examination revealed excoriating skin
lesions seen on both hands, lower forearms,
forehead, chest and large healed lesion with a scar
formation on lower back region
Figure 1: Excoriating scaly skin lesions on lower forearms
Case Report
• On intraoral examination, there were multiple
erythematous lesions with shallow ulceration on
lower lip and hemorrhagic crusted appearance on
right side of lower lip.
• A hemorrhagic lesion on hard palate, along with
melanin pigmentation on dorsal surface of tongue
and buccal mucosa was also noticed [Figure 2].
• Based on this atypical picture, we came to
differential diagnosis of pemphigus, erythema
multiforme, benign mucous membrane
pemphigoid, HIV associated lesions and syphilis. Figure 2: Multiple erythematous lesions with shallow healed
ulcerations and hemorrhagic crusted appearance on lower lip
Case Report
• The patient was advised blood investigations including complete
blood count, protein electrophoresis, antinuclear antibody test,
Venereal Disease Research Laboratory (VDRL) test, enzyme-
linked immunosorbent assay (ELISA) for HIV and HBsAg antigen
for Hepatitis B, biopsy with direct immunoflourescence (DIF) and
dark field microscopy [Figure 3].
• All the tests were found to be normal; DIF was negative as

only lymphocytes and plasmocytes with endothelial swelling were
visible;
• VDRL was seen to be reactive with high titer of 1:64 and
spirochetes were visible in dark field microscope.
Figure 3: DIF showing dense inflammatory infiltrate

composed of lymphocytes and plasmocytes with
endothelial cell swelling
Case Report
• Thus, on the basis of personal history,
clinical manifestation and positive VDRL
test and biopsy from lesion site, final
diagnosis of secondary syphilis was
made.
*Other more specific investigations like Treponema

pallidum magglutination Assay (TPHA) and Treponema
Pallidum Particle-Agglutination Test (TPPA) were not done
due to nonavailability and financial constraints.
Figure 3: DIF showing dense inflammatory infiltrate
composed of lymphocytes and plasmocytes with
endothelial cell swelling
Case Report
• The patient was treated with 2.4 MU
benzathine penicillin every week for 1
month.
• All the lesions healed completely after 1
month of medication, with no reoccurrence
after 3 months of follow-up [Figure 4].
• VDRL test was repeated and the titer
decreased to 1:32. Patient was counseled
and advised to be on regular follow-up after
every 3 months. Figure 4: Post-treatment photograph of
patient after 1 month of medication
Discussion
• The eruption of secondary syphilis has certain characteristics which help to identify and
distinguish it from other lesions.
• Typical mucous membrane lesions tend to be oval, serpiginous, raised erosions or ulcers
with an erythematosus border.
• There is an overlying gray or silver membrane.
• Sometimes, these lesions can appear as leukokeratosis and involve the tongue, the
mucosal lip, or the palate.
• Usually, the spirochetemia of secondary syphilis is associated with systemic symptoms
and a cutaneous eruption; rarely, there may be spirochetemia without cutaneous
manifestations.
Discussion
• The oral cavity is the most common extragenital site of infection, although isolated
oral ulcerations in secondary syphilis are unusual.
• In fact, there are only a few reports of secondary syphilis presenting with isolated oral
lesions.
• In contrast with oral lesions of primary syphilis, which tend to be solitary, painless,
indurated ulcers, oral lesions of secondary syphilis are typically painful and multiple.
• They are usually accompanied by a concomitant cutaneous eruption. [5],[6]
Discussion
• The differential diagnosis of oral lesions of secondary syphilis includes
erythema multiforme, stomatitis, pemphigus, lichen, candidiasis, oral
gonorrhea, and other STDs.
Conclusion
• Establishing a diagnosis of syphilis, whatever the stage of the disease, can
be difficult because syphilis is a great mimic in clinical morphology
and histology.
• Many patients infected with venereal diseases have oral manifestations,
but very few dentists and physicians have the proper experience to
diagnose syphilis or other STDs from oral lesions.
• Atypical oral lesions in high-risk group people should raise suspicion
toward infectious transmissible diseases.
Conclusion
• Early diagnosis of such cases reduces the morbidity and also
prevents further transmission of the disease.
• In recent years, the secondary syphilitic lesions found in oral cavity
have been noted as often atypical due to inadequate treatment as a
result of antibiotic therapy for unrelated infections and increasing trend of
association of syphilis with HIV infection.
• Attention should be paid to all suspicious lesions and stress on the
seriousness of these illnesses to prevent pandemic of STDs by early
diagnosis, education and referral.
Mucocutaneous Secondary Syphilis –
“the Great Imitator”
Pirabu Sakthivel, Aanchal Kakkar, Suresh Chander Sharma, Smriti Panda
Pirabu Sakthivel, Aanchal Kakkar, Suresh Chander Sharma, Smriti Panda, Mucocutaneous Secondary Syphilis
– “the Great Imitator”, The American Journal of Medicine (2017),
https://doi.org/doi:10.1016/j.amjmed.2017.10.017.
Case Report
• A 22-year-old man presented with multiple painless whitish oral mucous patches surrounded
by erythema localized over his right tonsil, soft palate, uvula, and upper pole of left tonsil for six
months (Panel A).
• There were no constitutional symptoms.
• A clinical diagnosis of oropharyngeal papillomas was made and a biopsy was performed. The
patient was prescribed tablet amoxicillinclavulanate 625mg thrice daily after biopsy, which led to
complete disappearance of lesions within 3 days.
• On further inquiry, history of being diagnosed with primary syphilis one year back was
elicited, for which he had received treatment.
• Physical examination revealed multiple scaly, coppery red plaques on bilateral palms and soles
(Panel B).
Pirabu Sakthivel, Aanchal Kakkar, Suresh Chander Sharma, Smriti Panda, Mucocutaneous Secondary Syphilis – “the
Great Imitator”, The American Journal of Medicine (2017), https://doi.org/doi:10.1016/j.amjmed.2017.10.017.
Case Report
Case Report
• Laboratory investigations revealed a positive Venereal Disease Research Laboratory [VDRL]
test (titer, 1:760; normal value, and Treponema pallidum hemagglutination assay [TPHA] (titer,
1:1250; normal value, <1:80)
• Serologic tests for human immunodeficiency virus and viral hepatitis were negative.
• Histopathological examination of the biopsy specimen obtained from the palatal lesion revealed
hyperplastic squamous epithelium with superficial ulceration and neutrophils; subepithelial tissue
showed inflammatory infiltrate rich in plasma cells (Panel C)
• Warthin-Starry stain demonstrated dark brown to black, slender, filamentous spiral bacteria,
15-20 micron in length, consistent with spirochetes (Panel D).
Case Report
• A diagnosis of secondary mucocutaneous syphilis was made.
• The patient received three intramuscular injections of 2.4 million units of benzathaine
penicillin G at weekly intervals, which led to complete resolution of the lesions
Discussion
• Patients with secondary syphilis typically manifest with systemic symptoms including
malaise, fatigue, fever, and headache as well as the hallmark rash, which is classically a
maculopapular coppery red rash diffusely involving the trunk and extremities including the
palms and soles.
• In secondary syphilis, oral manifestations can be present in one third to one half of all
patients.
• Oral lesions in secondary syphilis can be slightly elevated-type plaques, ulcerated
and covered with pseudomembrane, or multiple painless mucous patches that may
coalesce to give rise to serpiginous lesions, known as “snail-track ulcers”.3
Discussion
• The clinical and histological features of secondary mucocutaneous syphilis are non-
specific, and may mimic more common clinical conditions.
• Thus, a high index of suspicion and proper elicitation of history, particularly in societies
where the stigma of a sexually transmitted infection may prevent a patient from revealing
• His past history, are necessary among clinicians as well as pathologists in order to
arrive at the diagnosis of this treatable disease.
Kasper, D/ L., Fauci, A. S., Hauser, S. L., Longo, D.
L. 1., Jameson, J. L., & Loscalzo, J. (2015).
Harrison’s principle of internal medicine (19th
edition). New York: McGraw Hill Education. Page
1137
EVALUATION for NEUROSYPHILIS
• Involvement of the CNS is detected by
examination of
• CSF for pleocytosis (>5 white blood
cells/μL),
• increased protein concentration (>45
mg/dL), or VDRL reactivity.
• Elevated CSF cell counts and protein
concentrations are not specific for
neurosyphilis and may be confounded by HIV
co-infection.
• CSF white-cell cutoff of 20 cells/μL
• diagnostic of neurosyphilis in HIV-
infected patients with syphilis.
Kasper, D/ L., Fauci, A. S., Hauser, S. L., Longo, D. L. 1., Jameson, J. L., & Loscalzo, J.
(2015). Harrison’s principle of internal medicine (19th edition). New York: McGraw Hill
Education. Page 1138
OBJECTIVES
The objectives of these guidelines are:
• to provide evidence-based guidance on treatment
of Treponema pallidum; and
• to support countries to update their national
guidelines for treatment of Treponema pallidum.
• STIs have a direct impact on reproductive and child health through infertility, cancers
and pregnancy complications
• They have an indirect impact through their role in facilitating sexual transmission of
human immunodeficiency virus (HIV) and thus they also have an impact on national
and individual economies.
• More than a million STIs are acquired every day.
• In 2012, an estimated 357 million new cases of curable STIs (gonorrhoea, chlamydia,
syphilis and trichomoniasis) occurred among 15- to 49-year-olds worldwide, including
5.6 million cases of syphilis.
• There are an estimated 18 million prevalent cases of syphilis.
REVIEWS OF THE EVIDENCE
MAKING RECOMMENDATIONS
STRENGTH OF
RECOMMENDATION RECOMMENDATION AND
QUALITY OF EVIDENCE
In infants
1. Confirmed congenital syphilis
or, • Aqueous benzyl penicillin 100 000–
2. Infants who are clinically 150 000 U/kg/day intravenously for
normal, but whose mothers had 10–15 days Conditional
- untreated syphilis OR recommendation, very
- inadequately treated syphilis • Procaine penicillin 50 000 U/kg/day low quality evidence
(including treatment within 30 days single dose intramuscularly for 10–
of delivery) 15 days
- syphilis that was treated with
non-penicillin regimens,
In infants
Who are clinically normal and whose Close monitoring of the infants. Conditional
mothers had syphilis that was (Benzathine penicillin G recommendation, very
adequately treated with no signs of 50 000 U/kg/day single dose low quality evidence
reinfection intramuscularly)
Follow-up Evaluation
• Efficacy of treatment should be assessed by clinical evaluation and
monitoring of the quantitative VDRL or RPR titer for a fourfold decline (e.g.,
from 1:32 to 1:8).
• Patients with primary or secondary syphilis should be examined 6 and 12
months after treatment
• Persons with latent or late syphilis at 6, 12, and 24 months.
• More frequent clinical and serologic examination (3, 6, 9, 12, and 24 months)
• is recommended for patients concurrently infected with HIV, regardless
• of the stage of syphilis.
Syphilitic mucous patches:
the resurgence of an old classic
Josep E. Herrero-González, MD, Maria Elisabet Parera Amer, MD, Marta
Ferran Farrés, MD, Agustí Toll Abelló, MD, Carles Barranco, MD, and Ramon M. Pujol, MD
Herrero-González, J. E., Amer, M. E. P., Farrés, M. F., Abelló, A. T., Barranco, C., & Pujol, R. M. (2008).
Syphilitic mucous patches: the resurgence of an old classic. International Journal of Dermatology, 47(12), 1281–1283.doi:10.1111/j.1365-4632.2008.03862.x
Case Report
• A 20-year-old woman was referred to our department for evaluation of multiple persistent erosive
lesions of the oral mucosa that appeared 3 months before consultation.
• She complained of sore throat and a vague local discomfort. Her past medical history was
unremarkable.
Syphilitic mucous patches: the resurgence of an old classic. International Journal of Dermatology, 47(12), 1281–
1283.doi:10.1111/j.1365-4632.2008.03862.x
Case Report
• Physical examination disclosed
• symmetrical erosive serpiginous
hypertrophic plaques on the buccal
commissures and buccal mucosa
• whitish erythematous plaques on the tongue
surface and erosions of the lips (Fig. 1).
• Enanthem and a few small vesicles on the soft
palate were also observed.
• No similar mucocutaneous lesions were
present elsewhere.
• The patient was otherwise in a good general
status, with no fever or palpable enlarged lymph Figure 1 (a) Erythematous whitish plaques on the tongue. (b,c) Leukoplakia
and erosive plaques on the lips and commissures. (d) Palate enanthem
nodes.
1283.doi:10.1111/j.1365-4632.2008.03862.x
Case Report
• Two 4-mm punch biopsies were performed.
Histopathological study showed irregular
acanthosis with an intense, diffuse and
perivascular infiltrate in the submucosa (Fig. 2).
• A PAS stain failed to show any microorganisms
and direct immunofluorescence study was negative
1283.doi:10.1111/j.1365-4632.2008.03862.x
Case Report
• Immunohistochemical staining with a polyclonal
rabbit antibody against Treponema pallidum
revealed multiple spirochetes, mainly distributed in
the lower layers of the mucosa, adopting a honey-
comb pattern drawing the keratinocyte walls (Fig.
3).
• Microorganisms were also evident, although in a
much weaker amount, within the infiltrate in the
upper submucosa. Specific antitreponemal IgG
and nontreponemal tests (VDRL, titre 1/256) were
positive, with negative HIV-1/ 2 serology.
1283.doi:10.1111/j.1365-4632.2008.03862.x
Case Report
• The diagnosis of oral mucous patches (a form of
secondary syphilis) was established, in the
absence of other constitutional, genital, or skin
manifestations.
• Treatment with benzathine penicillin (2.4 MU) was
prescribed. The patient was lost for follow-up.
1283.doi:10.1111/j.1365-4632.2008.03862.x
Conclusion
• Oral manifestations of secondary syphilis are present in more than one-
third of patients presenting with the characteristic skin rash.
• Specifically, the mucous patches represents less than a 10% of cases of
the secondary stage of this infection.
• HIV-coinfection must always be ruled out in these cases, and syphilis
must be also considered in the differential diagnosis of oral lesions in all
HIV-infected patients.
1283.doi:10.1111/j.1365-4632.2008.03862.x
Conclusion
• Our report describes an atypical presentation of oral secondary syphilis, a
disease that can be easily misdiagnosed if not suspected, in the absence
of a suggestive skin rash and accurate epidemiological data.
• We attempt to emphasize the need of being aware of the broad spectrum
of clinical manifestations of syphilis, a potentially aggressive sexually
transmitted disease with an increasing incidence.
1283.doi:10.1111/j.1365-4632.2008.03862.x
Pustular secondary syphilis:
report of three cases and
review of the literature
Viktoryia Kazlouskaya1,2, MD, PhD, Christa Wittmann3 , MD, and Iryna Tsikhanouskaya4 , MD, PhD
Kazlouskaya, V., Wittmann, C., & Tsikhanouskaya, I. (2014). Pustular secondary syphilis:
report of three cases and review of the literature. International Journal of Dermatology, 53(10), e428–e431.doi:10.1111/ijd.12337
Case Report
Introduction
• Pustular syphilis is a known manifestation of secondary syphilis and is thought to be exceedingly rare.
• Descriptions of the disease are found in a limited number of case reports, most of which come from
developing countries.
• Failure to recognize the disease can have devastating consequences.
• Appropriately titled the great masquerader because of its masterful mimicry and variability in presentation,
the diagnosis can be missed by those not familiar with pustular variants.
• We present three patients diagnosed in Belarus with pustular syphilis as the primary manifestation of
secondary syphilis.
Patient 1
• A 28-year-old single woman was admitted with a new diagnosis of syphilis made during a routine medical
visit.
• The diagnosis was initially established on the basis of a Venereal Disease Research Laboratory (VDRL) test
(titers 1 : 32) and confirmed by enzyme immunoassay (EIA) for Treponema pallidum. Human
immunodeficiency virus (HIV) testing was negative.
• Skin examination revealed multiple superficial pustules resembling impetigo on the chin and nose. The
physical examination was otherwise unremarkable.
• The patient had assumed the lesions had been caused by a bacterial infection and consequently self-treated
with local antiseptics without improvement (Fig. 1).
• No signs of hard chancre or erosive lesions were detected on the vulva or vagina. The patient stated that the
lesions had been present for approximately two months and that her last unprotected sexual contact had
occurred about 6–7 months previously.
Patient 1
• Treponema pallidum was detected in exudate from the lesions by means of dark field microscopy.
• Because the duration of the disease was unknown, benzyl penicillin was administered at a dose of 1
million units IM for 21 days (on the basis of European guidelines for the treatment of sexually
transmitted diseases );
• this led to the complete resolution of the skin lesions within seven days.
Patient 1
Patient 2
• A 24-year-old patient was referred for multiple, disseminated cutaneous pustules, erosions, and crusts that
had been present for an indeterminate length of time (Fig. 2).
• The patient had attempted treatment with a local antiseptic (Fig. 2b).
• On examination, multiple lesions resembling ecthyma were observed, along with many pustules. The
pustules were superficial and filled with yellowish pus and, although they varied in shape, were mostly
annular in configuration.
• These lesions were accompanied by multiple punched out ulcers, measuring 1–5 cm in diameter, with oyster
shell-like crusts.
• A deep erosion with uneven borders and a purulent base was noted on the glans penis. Treponema pallidum
was detected by dark field microscopy performed on material from the base of the lesions.
Patient 2
• The patient reported multiple unprotected sexual contacts but could not recollect the duration of the
infection.
• The patient was screened for syphilis by VDRL (titers 1 : 64), which is typically performed in all patients at
their first visit to a hospital in Belarus, yielding a positive result.
• Testing for HIV infection was negative.
• The diagnosis of secondary syphilis was confirmed by EIA.
• Benzyl penicillin was administered as specified in Patient 1, and the remission of skin symptoms was seen
within 14 days. The lesions healed with only superficial scarring.
Patient 2
Patient 3
• A 21-year-old man presented with multiple penile lesions.
• The patient admitted to multiple unprotected sexual contacts in the past two years, the most recent of
which had occurred about six months previously.
• Multiple purulent lesions covered by thick oyster shell-like crusts were found on the penis shaft (Fig. 3).
• A diagnosis of secondary syphilis was established by VDRL (titers 1 : 128) and EIA.
• Treponema pallidum was detected by dark field microscopy.
• Testing for HIV infection was negative.
• Benzyl penicillin was administered in a similar manner as in Patients 1 and 2. The skin symptoms
demonstrated remission within 14 days and went on to heal with superficial scarring and secondary
hyperpigmentation.
Patient 3
Discussion
• The most commonly observed cutaneous presentation in secondary syphilis is a generalized, non-
pruritic, papulosquamous eruption varying from pink to violaceous to brown, with mucous
membrane involvement.
• Pustular lesions are less common and pose an even greater diagnostic challenge.
• In a study of 105 patients with secondary syphilis, Chapel found pustular lesions in about 1.9%
of patients.
• The largest series of patients with pustular syphilis was described by Siddappa and Madvamurthy,
who presented 21 cases with a male to female predominance of 2 : 1 collected during four years
of observation.
Discussion
• Pustular lesions more commonly affect individuals with poor health and malnutrition, and co-
infection with HIV is frequent
• Pustular syphilis can be divided into four main descriptive subgroups.
• Miliary pustular syphilis presents with small, 3–5-mm, perifollicular pustules.
• Acuminate syphilis takes two forms:
• acneiform syphilis usually localizes on the face and presents with papules and
papulopustules resembling those of acne vulgaris, and
• varioliform syphilis presents with pustules and central crusts that form punched out
even ulcers resembling those in varicella or smallpox infection.1
Discussion
• Flat variants of syphilis include
• impetiginoid syphilis, which presents with flat pustules and yellowish crusts, and usually
occurs on the face, scalp, and intertriginous areas, and
• ecthymiform syphilis, which presents with lesions measuring up to 5 cm in diameter that
form ulcers with an overlying crust.1
Discussion
• Pustulo-ulcerative crusted (rupioid) syphilis presents with pustules and papules that are
covered by thick oyster-like crusts.
• This form of syphilis is often accompanied by systemic involvement.
• Acuminate syphilis takes two forms:
• acneiform syphilis usually localizes on the face and presents with papules and
papulopustules resembling those of acne vulgaris, and
• varioliform syphilis presents with pustules and central crusts that form punched out
even ulcers resembling those in varicella or smallpox infection.
Discussion
• The immunopathogenesis behind the formation of pustules in secondary syphilis is unclear.
• The majority of cases show no infection by Staphylococcus aureus in the lesion, but cases
with staphylococcal infection and Treponema spp. in the lesion have been previously
described.

Syphilis - Final

Hochgeladen von

Dokumentinformationen

Originaltitel

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Syphilis - Final

Hochgeladen von

Copyright:

Verfügbare Formate

Atypical oral manifestations

Figure 1: Excoriating scaly skin lesions on lower forearms

• All the tests were found to be normal; DIF was negative as

Figure 3: DIF showing dense inflammatory infiltrate

*Other more specific investigations like Treponema

Das könnte Ihnen auch gefallen