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Dental Abscess As an Initial Presentation of Tertiary Syphilis: a Case Report Matthew Carey1, Jana Havranova1, Thong Le2

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Dental Abscess As an Initial Presentation of Tertiary Syphilis: a Case Report Matthew Carey1, Jana Havranova1, Thong Le2 International Journal of Medical and Dental Case Reports (2019), Article ID 060630, 2 Pages CASE REPORT Dental abscess as an initial presentation of tertiary syphilis: A case report Matthew Carey1, Jana Havranova1, Thong Le2 1Internal Medicine, St. Luke’s University Hospital, Bethlehem, PA USA, 2Department of Infectious Disease, St. Luke’s University Hospital, Bethlehem, PA USA Correspondence: Abstract Dr. Matthew Carey, Internal Recognize syphilis as a re-emerging disease, especially in the presence of HIV. Syphilis, Medicine, St. Luke’s University caused by the sexually transmitted spirochete Treponema pallidum, often occurs as Hospital, 801 Ostrum St. Bethlehem, PA 18018 USA. Phone: 925-413-8913. coinfection in HIV-infected patients, and its prevalence has increased in the United E-mail: [email protected] States. We report a case of oral gummata presenting as a dental abscess in an HIV- infected 25-year-old MSM with no prior history of syphilis. The patient’s rapid plasma Received 01 May 2019; reagin was positive at 1:512 dilution with positive confirmatory fluorescent treponemal Accepted 09 June 2019 antibody absorption test. Surgical exploration of the suspected abscess identified a 5-cm ulcerated mass eroding into the right maxillary sinus. Tissue gram stain and culture of the doi: 10.15713/ins.ijmdcr.118 mass revealed only mixed oral flora. Pathology revealed acute and chronic inflammatory granulation tissue, and the Warthin–Starry stain identified rare microorganisms, How to cite the article: suspicious for spirochetes. Our patient was treated for tertiary syphilis with intramuscular Carey M, Havranova J, Le T. Dental abscess benzathine penicillin G injections weekly for 3 doses. At 1-month follow up, the patient as an initial presentation of tertiary syphilis: was symptom-free. A case report. Int J Med Dent Case Rep 2019;6:1-2. Keywords: Gumma, HIV infection, spirochetes, tertiary syphilis Introduction rapid plasma reagin was positive at 1:512 dilution, with positive confirmatory fluorescent treponemal antibody absorption test. Syphilis, caused by the sexually transmitted spirochete Surgical exploration identified 5-cm ulcerated mass eroding Treponema pallidum, often occurs as a coinfection in HIV- into the right maxillary sinus. Tissue gram stain and culture of infected patients. Recently, syphilis prevalence has increased in the mass revealed only mixed oral flora. Pathology of the mass the United States. We report a case of oral gummata presenting revealed acute and chronic inflammatory granulation tissue. as a dental abscess in an HIV-infected MSM with no prior The Warthin–Starry stain identified rare microorganisms, history of syphilis. suspicious for spirochetes, performed with an appropriate control [Figure 2]. The patient was treated with intramuscular Case Report benzathine penicillin G injections weekly for 3 doses. At 1-month follow up, the patient was symptom-free. A 25-year-old, African-American MSM, recently diagnosed with HIV infection, was hospitalized with a 3-month history of right-sided facial swelling and dental abscess, not responding Discussion to antibiotics. On physical examination, he had mild trismus, right buccal induration without tenderness, and exudative Gummatous lesions are characteristic of tertiary syphilis and changes of the right upper molar. He was neurologically intact are often associated with AIDS and other sexually transmitted with normal mental status. Computed tomography of the facial diseases (STDs). Any organ can be affected. Oral lesions usually bones revealed a large defect in the floor of the right maxillary involve the midline of the palate, tongue, or tonsils; however, sinus with extensive opacification of the right maxillary sinus our case demonstrates perforation into the maxillary sinus.[1-4] and a soft-tissue density extending through the maxillary floor While the gumma represents a granulomatous inflammatory defect into the adjacent soft tissues, indicating possible chronic response to spirochetes, these are rare in gummas and osteomyelitis with bony destruction and the possibility of Warthin–Starry staining may only identify few spirochetes if malignancy [Figure 1a and b]. Laboratory studies included HIV at all, making the diagnosis challenging.5-6 We emphasize that viral load (120,740 copies/ml), CD4 count (90/µL), negative syphilitic gumma should be considered in the differential of cytomegalovirus, and toxoplasma antibodies. The patient’s large nontender indurated oral lesions unresponsive to typical 1 Carey, et al. Tertiary syphilis presenting as dental abscess Conclusion Syphilis is a re-emerging disease in HIV-infected individuals and should be considered in the differential diagnosis of atypical oral lesions unresponsive to antibiotics. Clinical significance Coinfection of HIV is associated with rapid progression of a b syphilis. It is imperative to include syphilis in the differential Figure 1: (a) Coronal view of computed tomography (CT) scan of diagnosis of HIV-infected patients presenting with atypical oral facial bones demonstrating almost complete opacification of the lesions. This case illustrates the need to recognize the increased right maxillary sinus and extension of this soft-tissue density to the surrounding adjacent tissue. (b) Sagittal view of CT scan of facial prevalence of syphilis in HIV-infected patients and its rapid bones revealing erosion of the maxillary floor with invasion of a progression into tertiary syphilis. soft-tissue density Acknowledgments Dr. Santo Longo, our pathologist, with St. Luke’s University Hospital performed immunohistochemical staining and provided the pathology images for this case. References 1. Cherniak W, Silverman M. Images in clinical medicine: Syphilitic gumma. N Engl J Med 2014;371:667. 2. Leão JC, Gueiros LA, Porter SR. Oral manifestations of syphilis. Clinics (Sao Paulo) 2006;61:161-6. 3. Leuci S, Martina S, Adamo D, Ruoppo E, Santarelli A, Sorrentino R, et al. Oral syphilis: A retrospective analysis of 12 cases and a review of the literature. Oral Dis 2013;19:738-46. Figure 2: Immunohistochemical stain for spirochetes from a sample 4. Scott CM, Flint SR. Oral syphilis re-emergence of an old taken from the oral maxillary ridge at ×400. Spirochetes are seen in disease with oral manifestations. Int J Oral Maxillofac Surg various degrees of degeneration with an intact spirochete indicated 2005;34:58-63. by the arrowhead 5. Carlson JA, Dabiri G, Cribier B, Sell S. The immunopathobiology of syphilis: The manifestations and course of syphilis are determined by the level of delayed-type hypersensitivity. Am J antibiotics for odontogenic infections, especially in a patient Dermatopathol 2011;33:433-60. [3] with concurrent STDs. Coinfection with HIV is associated 6. Charlton OA, Puri P, Davey L, Weatherall C, Konecny P. Rapid with rapid progression to tertiary syphilis as little as several progression to gummatous tertiary syphilis in a patient with months.[5,6] HIV. Australas J Dermatol 2019;60:e48-50. This work is licensed under a Creative Commons Attribution 4.0 International License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/ © Carey M, Havranova J, Le T. 2019 2.
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