|Year : 2014 | Volume
| Issue : 4 | Page : 436-438
An unusual manifestation of secondary syphilis: A case report
Thimmarasa Venkappa Bhovi1, Manas Gupta1, Parvathi Devi2, Abhishek Pachauri3
1 Department of Oral Medicine and Radiology, Rishiraj College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of Oral Medicine and Radiology, Teerthankar Dental College Hospital and Research Centre, Moradabad, Uttar Pradesh, India
3 Department of Oral and Maxillofacial Surgery, Mahatma Gandhi Dental College, Jaipur, Rajasthan, India
|Date of Submission||13-Nov-2014|
|Date of Acceptance||09-Apr-2015|
|Date of Web Publication||22-Apr-2015|
Thimmarasa Venkappa Bhovi
Department of Oral Medicine and Radiology, Rishiraj College of Dental Sciences and Research Centre, Bhopal - 462 036, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Syphilis is an infectious disease presenting different stages each of which are associated with specific oral lesions. Oral lesions in secondary stage syphilis are particularly common in association with general symptoms and cutaneous eruptions. However, an exclusive oral localization, not associated with general manifestations, is uncommon. We report a case of a 27-year-old male patient with isolated oral ulceration as the sole presentation of secondary syphilis.
Keywords: Oral lesions, secondary stage, syphilis
|How to cite this article:|
Bhovi TV, Gupta M, Devi P, Pachauri A. An unusual manifestation of secondary syphilis: A case report. J Indian Acad Oral Med Radiol 2014;26:436-8
|How to cite this URL:|
Bhovi TV, Gupta M, Devi P, Pachauri A. An unusual manifestation of secondary syphilis: A case report. J Indian Acad Oral Med Radiol [serial online] 2014 [cited 2022 Dec 1];26:436-8. Available from: http://www.jiaomr.in/text.asp?2014/26/4/436/155642
| Introduction|| |
Syphilis is an acute and chronic sexually transmitted disease (STD). It is caused by the microorganism, Treponema pallidum which produces skin and mucous membrane lesions.  In 1530, Girolamo Fracastoro, an Italian physician and poet, coined 'syphilis' and mentioned it in his poem titled "Syphilis sive morbus glallicus" (Latin for "Syphilis or the French disease"). Syphilus (perhaps a variant spelling of Siphylus, a character in Ovid's metamorphoses), a shepherd, was the name of the central character in the poem. Syphilis is said to have evolved between 15,000 and 3,000 BC, and transported to Asia by Portuguese sailors led by Vasco da Gama.  Secondary syphilis produces multiple lesions often affecting several oral sites, but most characteristically manifests as white plaques (mucous patches), which fuse to form snail track ulcers.  We present our case because of the rare presentation of localized oral lesions of secondary syphilis for past one and half year with the absence of skin lesions. There are only a few reports of secondary syphilis presenting with isolated oral lesions. Moreover, we emphasize the atypically long duration of the oral involvement with secondary syphilis, which is a highly infectious disease.
| Case Report|| |
A 27-year-old male patient reported to the department of Oral Medicine and Radiology with the chief complaint of an ulcer in the mouth since 3 weeks. Patient gave a history of recurrent ulcers for the past 1 year at an interval of about 6 months. It was the third time that the ulcer had occurred which was present for the past 3 weeks. It was initially small which gradually increased to the present size, and was associated with mild, dull and intermittent pain. There was no significant history of exposure to allergens, blood transfusion and medication.
On general physical examination, the patient was moderately built and nourished, and all his vital signs were within normal limits. Bilateral submandibular lymph nodes were palpable, which were mobile and non-tender. Intraoral examination revealed irregular shallow ulcerative lesions covered with greyish white pseudomembrane with an erythematous border present on both the right and left buccal mucosa, and lower and upper labial mucosa measuring approximately 1 × 1.5 cm, 1 × 3.5 cm, 0.5 × 1 cm and 0.5 × 1 cm in size, respectively, associated with crusting present at the junction of vermilion border and upper labial mucosa. All the ulcerative lesions were tender and did not bleed on palpation [Figure 1]a-b and [Figure 2]a-b. Based on the history and clinical examination we arrived at a provisional diagnosis of pemphigus vulgaris with the following differential diagnosis: Erythema multiforme, erosive lichen planus, allergic stomatitis, erythematous candidiasis and sexually transmitted diseases.
|Figure 1: Lesion on the (a) right buccal mucosa, and (b) left buccal mucosa|
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|Figure 2: Lesion on the (a) upper labial mucosa, and (b) lower labial mucosa|
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Hematological investigations showed that all the values were within normal limits except for an increased ESR. An incisional biopsy of the right buccal mucosa lesion was performed and the histopathological features revealed moderately hyperplastic and keratinized epithelium with focal ulceration and exudate. There was dense plasma cell infiltrate in the superficial and deep layers of connective tissue with an ill-defined collection of histiocytes [Figure 3]a and b. These findings were suggestive of a secondary syphilitic lesion. Based on the histopathological analysis, the patient was re-evaluated and he did not have any skin or genital lesions. Further the patient denied any extramarital sexual relationship. So further serological tests were carried out which revealed a positive venereal diseases research laboratory (VDRL) test, Treponema pallidum hemagglutination assay (TPHA) value of 1/160 and negative ELISA test for HIV.
|Figure 3: Photomicrograph at (a) lower magnification showing dense infiltrate of plasma cells, and (b) higher magnifi cation showing plasma cell infi ltrate with collection of histiocytes|
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Clinical data, histopathological analysis and results of the serological tests led us to a final diagnosis of secondary syphilis. We treated the patient with penicillin G benzathine, 1.2 million units each week, for 3 weeks along with betamethasone 4 mg intramuscular injection each week for 2 weeks to avoid Jarisch-Herxheimer reaction. Complete resolution of the lesions was obtained within 10 days [Figure 4]a-c. There was no recurrence of the lesions after a follow-up period of 3 months.
|Figure 4: Complete resolution of the lesion on the (a) upper labial mucosa, (b) lower labial mucosa, and (c) right buccal mucosa|
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| Discussion|| |
Syphilis is caused by T. pallidum, a spirochete, and is characterized by episodes of active disease interrupted by periods of latency. Treponema pallidum is a Gram positive, motile, slender, fragile and microcephalic spirochete which is pathogenic to humans and can best be demonstrated by the dark field microscope with a fresh specimen since it stains poorly (except by silver impregnation). , It is believed that T. pallidum does not invade via completely intact mucosal epithelium, minute abrasions or hair follicles. Within a few hours after invasion, bacterial spread to the lymphatics and blood stream occurs, resulting in early widespread dissemination of the disease. The earliest response to the bacterial invasion is an endarteritis and periarteritis. 
Syphilis was a prevalent disease, infecting 8-14% of the population before the advent of the penicillin in the mid-20 th century.  Transmission occurs via oral-genital, oral-anal, or other sexual contact with contaminated material, and through intra-uterine transmission.  Syphilis can be classified as either congenital or acquired.  The acquired form can be classified as primary, secondary, latent, and tertiary, depending on the elapsed time after exposure; primary infection occurs after 2-3 weeks, secondary infection 4-6 weeks after infection and late syphilis is present for more than 1 year. Congenital form may be seen in unborn children of women with untreated syphilis during pregnancy. 
The symptoms and signs of secondary syphilis include fever, malaise and generalized eruptions of the skin and mucous membrane. The oral manifestations of secondary syphilis are more extensive and/or variable. , Mucous patches are highly infectious, since they contain vast number of organisms.  The lesions of the secondary stage undergo spontaneous remission within a few weeks, but exacerbations, may continue to occur for months or several years.  Isolated oral ulcerations in secondary syphilis are unusual. Very rarely oral ulcerations may be the only manifestations of infection. , In the present case irregular shallow ulcerative lesions covered with pseudomembrane and an erythematous border were seen which is the only manifestation of secondary syphilis in the oral cavity. Typical mucous membrane lesions tend to be oval to crescentric erosions or shallow ulcers of about 1-cm diameter, covered by grey mucoid exudate with an erythematous border. , The patches usually arise bilaterally on the mobile surfaces of mouth, although the pharynx, gingiva, tonsils and very rarely the hard palate can be affected.  In some cases these mucous patches coalesce together to form serpiginous lesions called as snail track ulcers. 
The first serologic technique to diagnose syphilis was described by Wasserman in 1904. Serologic tests for syphilis are divided into two categories, non-treponemal and treponemal serologic tests. In non-treponemal serologic tests, such as VDRL and Rapid Plasma Reagin (RPR), the antibodies to be measured are non-specific treponemal antibodies. Treponemal serologic tests such as Fluorescent Treponemal Antibody Absorption (FTA-ABS), TPHA and Enzyme Immunoassay (EIA) are more complex, based upon the detection of specific antibodies to cellular components of T. palladium, which are used for confirmation. , Detailed description of the histopathological features of oral syphilis are scarce, possibly because of the rarity with which oral diseases is biopsied. One of the key microscopic features is plasma cell infiltration, at least in primary and secondary disease. Perivascular infiltrate with a preponderance of plasma cells are, however, common in oral biopsies which extend deep into the submucosa. , The current medical management of syphilis includes the use of parenteral long-acting benzathine penicillins. Alternate drugs for patients allergic to penicillin include oral doxycycline and oral tetracycline. ,
| Conclusion|| |
Syphilis is a highly infectious disease with extremely varied clinical manifestations. In the present case, we emphasize the atypically long duration of oral involvement of secondary syphilis.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]