A Case of Secondary with Oral Findings Natalie Steinhoff, DO,* Brian Wanner, DO,** Richard Miller, DO, FAOCD***

* Resident, PGY-4, Nova Southeastern University College of Osteopathic Medicine, Largo Medical Center, Largo, FL **Traditional Rotating Intern, PGY-1, Nova Southeastern University College of Osteopathic Medicine, Largo Medical Center, Largo, FL ***Dermatologist and Clinical Faculty, Nova Southeastern University College of Osteopathic Medicine, Largo Medical Center, Largo, FL

Disclosures: None Correspondence: Natalie Steinhoff, DO; Nova Southeastern University College of Osteopathic Medicine, Largo Medical Center, 201 14th St. SW, Largo, FL 33770; [email protected]

Abstract The incidence of syphilis has been on the rise, becoming a major global health problem. Syphilis is the “great imitator” of disease, requiring clinicians and public-health consultants to familiarize themselves with a variety of presentations in order to recognize it.1-4 We present the case of a young, HIV-positive male with secondary syphilis, focusing on oral manifestations of the disease and the need to have syphilis on the differential when oral lesions of unknown significance are present.

Introduction of including syphilis on the differential when oral Pathological examination of the specimens with a Humans are the only known natural hosts to the lesions are present. spirochete stain demonstrated numerous spirochetes Treponema pallidum, the spirochete in the and superficial dermis Figures( 4, 5). bacterium that causes syphilis. Multiple reports Case Report Acid-fast bacterial stain for mycobacteria was negative, A 27-year-old male with a past medical history suggest that while the global prevalence of syphilis as was Grocott’s methenamine silver and periodic of hepatitis, tuberculosis, Crohn’s disease, and had been decreasing, the disease is now reemerging acid-Schiff stains for fungi. The patient was referred to 1-4 HIV presented with a three-week history of as a significant public health concern. Sexual infectious disease for treatment with 2.4 million units painful red and plaques all over his body intercourse is the main route of transmission, with of intramuscular benzathine penicillin G. (Figure 1). He also reported ulcers on his tongue genital organs being the main sites of inoculation. and upper gum that started around the same time The oral cavity and anal region can also be as the skin lesions. affected. Transmission through the placenta during pregnancy (congenital syphilis) and through contact On examination, the patient had multiple, irritated, with a syphilis lesion via kissing, breastfeeding, and erythematous, scaly papules and patches distributed mouth-to-mouth transfer of prechewed food have 5-7 over his skin, including on the palms and soles also been reported. (Figures 2, 3). Oral examination demonstrated erythematous ulcers with crust located on the dorsal Syphilis progresses in four stages: primary, secondary, tongue and upper gum. No lymphadenopathy was latent, and tertiary. The primary stage classically present. Two biopsies of the cutaneous lesions were presents with a typically painless, self-healing . performed to rule out secondary syphilis, guttate The lesion develops at the site of inoculation and 6,8 , viral , , pityriasis has an incubation range of three days to 90 days. lichenoides chronica, , lymphoma, The secondary stage can manifest within weeks to and . a few months after the primary stage and presents Figure 3. Skin manifestations of secondary with one or more systemic findings including fever, headache, malaise, general lymphadenopathy, syphilis on the right palm. weight loss, , and/or alopecia, among others. Rash is the most characteristic finding of secondary Figure 4 syphilis and has myriad presentations.2,6,9 In the latent stage, no symptoms are present, but the individual is sero-reactive. Latent syphilis acquired in the last year is termed early latent syphilis; all other cases are termed late latent.5,6 Patients with cardiovascular or gummatous syphilis are in the tertiary phase.

Syphilis with central nervous system involvement is termed neurosyphilis. Neurosyphilis can occur during any stage of the disease, presenting with Figure 1. Painful, red papules and plaques cognitive dysfunction, motor and sensory deficits, ataxia, paralysis, tabes dorsalis, Argyll Robertson disseminated over the skin. pupils, and other neurological symptoms.2,3,5,8 Figure 5

Oral manifestations of syphilis vary widely and can mimic other, more common oral diseases. Oral lesions observed in the primary stage are Figure 2 associated with oral sex habits. Oral lesions in secondary syphilis, on the other hand, are part of a systemic process and are much more common, presenting in one third to one half of all secondary syphilis patients. Common oral presentations in the secondary stage include painless aphthous ulcers, lesions with whitish edges and irregularly shaped borders, and verrucous papules or plaques.5,9,10

This case report describes an HIV-positive patient Figures 4, 5. Spirochete stains with secondary syphilis and associated oral Figure 2. Irritated, erythematous, scaly of demonstrating spirochetes in the epidermis ulcerations. The case highlights the importance secondary syphilis. and superficial dermis.

A CASE OF SECONDARY SYPHILIS WITH ORAL FINDINGS Discussion Demonstration of spirochetes on histopathological References In the past decade, syphilis has re-emerged as a examination, along with clinical assessment, led to a 1. Anid G, Isaac M, Penner CR, Van Caeseele P, Tsang significant global health problem. Its reputation as presumptive diagnosis of secondary syphilis. RSW, Kadkhoda K. A non-healing syphilid: Another “the great imitator” can cause clinical recognition face of the great imitator. IDCases [Internet]. 2017 Treatment of secondary syphilis involves a to be difficult. Clinicians need to be aware of the Feb [cited 2017 July 25];8:14–6. Available from: parenterally administered dose of penicillin G, with various presentations of syphilis, including oral https://doi.org/10.1016/j.idcr.2017.02.005. preparation dependent on the stage of syphilis. A manifestations. 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STEINHOFF, WANNER, MILLER