Am J Ro.ntg.nol 127:789-792.

1976 789
Radiographic Findings in Early Acquired Syphilis:
Case Report and Critical Review
IRVING EHRLICH AND MORRIE E. KRICUN
Discussion
The radiographic and pathophysiologic features of early
acquired syphilis are discussed. Bone changes occur in
early acquired syphilis and should not be confused with
gummas of late syphilis. The radiographic findings are
protean and may exist without a clinical history of a
cutaneous lesion. The skull, clavicle, and tibia are the sites
most frequently involved.
Introduction
The osseous changes of early acquired syphilis are rare
and have not been emphasized in recent radiologic litera-
ture and textbooks on bone disease ( 1-3j. W e recently
examined a case of syphilitic osteoperiostitis that occurred
during the early phase of the secondary stage of
this disease.
Case Report
A 35-year-old black male was well until 4 weeks prior to
admission when he noted constant aching pain in the calves with
slight muscle weakness and aching and tenderness of the ankles.
He noted an eruption on the palms and soles at the time his
muscle and joint pain began. There was no history of syphilis
contact or treatment for syphilis. Physical examination showed
a well nourished patient in no acute distress. There were hyper-
pigmented keratotic macules on the palms and soles bilaterally.
compatible with secondary syphilis. There was also swelling of
the pretibial area bilaterally. The remainder of the examination
was unremarkable.
Fluorescent treponemal antibody absorption was positive. and
the rapid plasma reagin was reactive at a 1 :64 dilution. Radio-
graphs disclosed multiple aggressive osteolytic lesions in the
cortex of the tibiae, fibulae, ulnae, and radii (figs. 1 and 2) with
solid periosteal reaction in several locations. There was minimal
destruction of the proximal aspect of the second metacarpal
along with solid periosteal reaction (fig. 3). No lesions were
present in the skull, clavicles, other long bones, ribs. spine, or
feet.
Biopsy of the left fibula disclosed necrotic bone with inflam-
matory cell infiltrate composed mostly of mature plasma cells.
The vascularity was prominent and the endothelial cells were
swollen and pleomorphic. Spirochetes were identified within the
inflammatory cell exudate. The pathologic diagnosis was syphi-
litic periostitis and osteitis.
The patient was treated with 12 million units of procaine
penicillin intramuscularly over a 10 day period. During hospitali-
zation, he developed herpes zoster and molluscum contagiosum.
Aadiographs 1 month later showed no change in the appearance
of the lesions, but after 3 months there was almost complete
resolution of the lesions (fig. 4).
Osseous syphilis was first described in 1886 [4], but
it was not until 1 932 that radiographic evidence of osseous
change in early acquired syphilis was first reported [5, 61.
The incidence of radiographically diagnosed bone disease
is rare. In 1942, Reynolds and W asserman [71 reviewed
1 5 cases reported between 1 932 and 1 940 and added
1 5 of their own. Their cases came from a series of 10,000
patients with early acquired syphilis over a 21 year period
from 1 91 9-1 940. Bone lesions have been demon-
strated radiographically in a total of 52 reported cases,
including the present case [5-261. Osseous changes occur
in 0.1 5%-8.7% of patients with early acquired syphilis [8].
Clinical Features
Bone changes occur as early as 6 weeks after the
primary chancre to as late as 14 months after the secon-
dary skin eruption. In several cases, bone changes de-
veloped with the cutaneous eruption of secondary syphilis
[7]. The degree of bone destruction is usually more
severe than the clinical symptomatology [27-29]. Clin-
ically there may be pain, soft tissue swelling, tenderness,
headache, fever, and other constitutional symptoms. The
characteristic dermatologic change of secondary syphilis
is a maculopapular rash over the palms and soles. It must
be realized that early syphilitic osteomyelitis may occur
without a history of primary or secondary cutaneous
lesions and, in fact, may develop a short time after blood
transfusion [1 6, 20]. Also, the serologic test for syphilis
may not be positive when bone lesions occur [5. 1 71.
Pathophysiology
The spirochetemia and mucocutaneous lesions of secon-
dary syphilis occur 1 -3 months after the primary chancre.
During this stage, spirochetes may be disseminated hema-
togenously throughout the body and found in the perios-
teum, Haversian canals, and medullary space of all bones
[30]. Several investigators [25, 31 , 32] state that syphilis
of bone begins as an osteomyelitis in the medullary space
and spreads by way of blood vessels in the Haversian
canals to the cortex and periosteum.
Spirochetes induce a perivascular response followed by
muscularis atrophy, endothelial proliferation, and subse-
quent endarteritis obliterans [17, 30]. These vascular
changes are the cause of osteochondritis, periostitis,
osteitis, or osteomyelitis depending on which part of the
bone is involved. The vascular changes lead later to secon-
Received March 15, 1976; accepted after revision June 16. 1976.
Department of Diagnostic Radiology, Hahnemann Medical College and Hospital. 230 North Broad Street, Philadelphia. Pennsylvania 19102. Address
reprint requests to M. E. Kricun.
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2. Greenfield GB: Radiology of Bone Diseases, 2d ed. Phila-
delphia, Lippincott. 1975
.: . C 3, MUrray RO, Jacobson HG : The Radiology of Skeletal Dis-
orders. Exercises in Diagnosis. Baltimore, W illiams & W ilkins,
EARLY ACQUIRED SYPHILIS 791
- References 37-48. while not cited. have been included for the
interested reader.
dary ischemia and caseation necrosis-the gumma of
late syphilis [17].
Anatomic Distribution
The skull and clavicle, followed by the tibia, humerus,
ulna, and radius, are the sites most frequently involved
in early acquired syphilis. Other sites reported with less
frequency are the femur, fibula, sternum, ribs, scapula,
bones of the hands and feet, nasal bones, facial bones,
palate, knee, ileum, ischium, and spine.
Radiographic Features
The response of bone to the spirochete attack in early
acquired syphilis depends on the virulence of the organism,
host response, and the area of bone involved. Periostitis,
osteomyelitis, and osteitis manifested by periosteal reac-
tion, bone destruction, or sclerosis may occur alone or
in combination and may be localized or diffuse. Periosteal
reaction is usually laminated or solid, but can be perpen-
dicular simulating an osteosarcoma [1 7, 28, 33]. Osteo-
myelitis causes osteolytic changes in the cortex and
medullary space, usually with an aggressive pattern of
bone destruction.
Skull lesions appear as irregular areas of bone destruc-
tion; the outer table is more frequently involved than the
diploae and inner table. There may be soft tissue swelling
and wavy periosteal reaction [7].
In the long bones sequestration [1 7. 31 ], pathologic
fracture [6, 31 , 34], epiphyseal separation [31 ], and even
syphilitic arthritis [32] may occur as sequelae. Sequestra
in syphilis are difficult to visualize radiographically because
they are small and usually occur in cancellous bone [17].
It should be stressed that the destructive lesions in early
acquired syphilis are those of osteomyelitis and do not
represent gummas.
Differential Diagnosis
Syphilis has long been called the great imitator, and the
differential diagnosis of bone changes reflects this state-
ment. Aggressive-appearing osteomyelitis with or without
periostitis may simulate pyogenic osteomyelitis, metastatic
disease, histiocytosis, lymphoma, leukemia, tuberculosis,
fungal disease, and Ewings sarcoma [7, 1 3, 1 7, 27, 29,
34-36]. An osteoperiostitis may simulate osteogenic sar-
coma [17, 28, 33].
ACKNOW LEDGMENTS
Drs. Hugh Bennett and Ronald Shore were responsible for
primary care and follow-up of this patient. W e thank Carol
Garifo for excellent secretarial assistance.
REFER ENCES
1. Edeiken J, Hodes PJ: Roentgen Diagnosis of Diseases of
Bone. 2d ed. Baltimore, W illiams & W ilkins, 1973
1971
4. Lancereaux E: Les ost#{233}ites syphilitiques. Ann Dermatol
Syphiligr (Paris) 7 :26 1 , 1886
5. Nitchew L: A propos des ost#{233}o-p#{233}riostites syphilitiques pr#{234}-
coces. Ann Malad Vener 27:600-605, 1932
6. Gougerot MM, Mathieu P. Jais: Fracture spontan#{233}e de Ia
clavicule au debut de Ia syphilis secondaire. Ann Ma!ad
Vener27:31, 1932
7. Reynolds FW , W asserman H: Destructive osseous lesions
in early syphilis. Arch Intern Med 69:263-276, 1942
8. Bauer MF, Caravati CM: Osteolytic lesions in early syphilis.
Br J Vener Dis 43: 1 75-1 77, 1967
9. Bloom P: Destructive osteitis and facial paralysis in secon-
dary syphilis. Arch Dermato! Syph 29:940, 1934
10. Burrows HJ: Pathological fracture of the humerus compli-
cating late secondary syphilis. Br J Surg 24:452, 1937
1 1 . Cabanel G. Phelip X, Gintz B: Ost#{233}ite cranienne lacunaire de
Ia syphilis secondaire. Presse Med 79:1755-1756, 1971
1 2. Dillingham FH, McCafferty LK: Bone syphilis. Am J Syph
10:378-382, 1926
13. Exley M. Newton AW : Osseous syphilis. N Eng!J Med 234:
661-664, 1946
1 4. Farina A: Su un caso di osteomielite gummosa nel periodo
precoce della lue. G Med Mi! 87:59, 1939
1 5. Lefkovits AM, Cross KR: Bone lesions in early syphilis.
Am J Clin Patho! 1 6:693-700, 1946
1 6. Mandelbaum H. Saperstein AN: Transmission of syphilis by
blood transfusion: a case of acute gummatous osteomye-
litis.JAMA 106:1061, 1936
1 7. Metcalfe JW : Syphilitic osteoperiostitis-skull, ribs, and
phalanges. USN Med Bull 49:528-535, 1949
1 8. Newman BA, Saunders HC: Skeletal system manifestations
during secondary syphilis. NY State Med J 38:788-795,
1938
19. Parker JDJ: Uncommon complications of early syphilis.
Hepatitis, periostitis. iritis with papillitis. and meningitis. Br
J Vener Dis 48:32-36, 1972
20. Pi#{225}n HC. Frazier CN: Transfusion syphilis with widespread
osteomyelitis and cutaneous lesions of an erythema multi-
forme type. Chin Med J 57:301 , 1940
21 . Squires JB, W einer AL: Osteitis in early syphilis: report of a
case. Arch Dermato! Syph 39:830, 1939
22. Tauber EB, Goldman L: Syphilitic anemia with diffuse osteitis
and superinfection. Am J Syph Neurol 1 9:339, 1935
23. Thompson AG, Leedham CL, Hailey H: Osteomyelitis of the
skull in early syphilis. Report of two cases probably influ-
enced by trauma. Am J Syph Gonn Vener Dis 33:34-42,
1949
24. Thompson AG. Preston RH : Lesions of the skull in secondary
syphilis. Am J Syph Gonn Vener Dis 36:332-341 , 1952
25. Truog CP: Bone lesions in acquired syphilis. Radiology 40:
1-9, 1943
26. W ile UJ, W elton DG: Early syphilitic osteomyelitis with a
report of two cases. Am J Syph Gonn Vener Dis 24:1-12,
1940
27. Galvin AH: Syphilis of the osseous system. Am J Syph
12:187-193, 1928
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o
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y
r
i
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h
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R
R
S
.

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o
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p
e
r
s
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EHRLICH AND KRICUN
28. Sante LA: Radiographic manifestations of syphilitic diseases
ofbone.AmJSyph 12:510-516, 1928
29. Ungerman AH, Vicary W H. Eldridge W W : Luetic osteitis
simulating malignant disease. Am J Roentgenol 40:224-
229. 1938
30. Robbins SL: Pathologic Basis of Disease. Philadelphia,
Saunders, 1974
31 . Speed JS. Boyd HB: Bone syphilis. South Med J 29:371 -
377, 1936
32. W are MW : Syphilis of the bones and some radiographic
findings. Ann Surg 46:199-205, 1907
33. Skapinker S. Minnaar D: Syphilitic disease of the long bones
in the Bantu. J Bone Joint Surg 33-B:578-583, 1951
34. Olmstead EG: Gummatous osteomyelitis with pathologic
fracture complicating general paresis. Am J Syph 32:243-
250, 1948
35. Carman AD: A review of the roentgenology of syphilis. Am
JSyph 2:297-343, 1918
36. Johns D: Syphilitic disorders of the spine. J Bone Joint Surg
52-B:724-731, 1970
37. Alexander U, Schoch AG: Osseous syphilis. Am J Syph
Gonn Vener Dis 26:397-406, 1942
38. Bailey GG: Manifestations of bone syphilis. Urol Cut Rev
49:11-12, 1945
39. Bingold AC: Luetic lumbar spondylitis. Proc R Soc Med
55:354-355, 1962
40. Francis HC, Kampmeier RH: The bone lesions in acquired
tertiary syphilis. South Med J 36:556-559, 1943
41 . Holmes GW . Lingley JR: Roentgenologic manifestations of
syphilis. N EnglJ Med 217:983-987, 1937
42. Karaharju EO. Hannuksela M: Possible syphilitic spondylitis.
Acta Orthop Scand 44:289-295, 1973
43. Nathan AS, Lawson W : Syphilitic osteomyelitis of the
mandible. Oral Surg 1 7:284-288, 1964
44. Rost GS: Roentgen manifestations of Bejel (endemic syphi-
lis) as observed in the Euphrates River Valley. Radiology
38:320-325, 1942
45. Roy RB, Laird SM: Acute periostitis in early acquired
syphilis. Br J Vener Dis 49:555, 1973
46. Stewart DM: Roentgenological manifestations in bone syphi-
lis. Am J Roentgenol 40:2 1 5-223, 1938
47. Stokes JH, Beerman H, Ingraham NR Jr: Modern Clinical
Syphilology, 3d ed. Philadelphia, Saunders, 1944
48. W ile UJ, Senear FE: A study of the involvement of the bones
and joints in early syphilis. Am J Med Sci 1 52:689-693,
1916
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