18/9/2014

Isolated oral erosions: An unusual manifestation of secondary syphilis [eScholarship]

Dermatology Online Journal

UC Davis

Isolated oral erosions: An unusual manifestation of secondary syphilis

M Carlesimo, E Palese, E Mari, G Feliziani, M La Pietra, G De Marco, G Camplone
Dermatology Online Journal 14 (2): 23

U.O.C. Dermatology, II Unit University of Rome "La Sapienza"

Abstract
The oral cavity is the most common extragenital site of infection. We report a case of a 50-year-old female with isolated oral ulceration as the
presenting manifestation of secondary syphilis. In contrast with the oral lesions of primary syphilis, which tend to be solitary, painless,
indurated ulcers, oral lesions of secondary syphilis are typically painful, multiple, and accompanied by a concomitant cutaneous eruption.
Syphilis is an ancient spirochetal illness with myriad dermatologic and systemic manifestations; for this reason it is called the great imitator.
The incidence of many sexually transmitted diseases is increasing; we are noting re-emergence of old diseases and altered clinical scenarios.
Oral lesions in second-stage syphilis are particularly common when associated with general symptoms and cutaneous eruption. However, the
exclusive oral localization, not associated with general manifestations, is uncommon [1, 2]. We report a case of isolated oral ulceration as the
sole presentation of secondary syphilis.
Clinical synopsis
In November 2005 a 50-year-old female was admitted to our dermatology unit for a 5-month history of
painful ulcerations that presented exclusively in her mouth. The lesions were circular, tender, serpiginous
erosions, with a "snail-track" appearance and an erythematosus border (Fig. 1). Physical examination did
not reveal skin or genital lesions and the patient stated that she had not had any such lesions in the past
5 months. She had submandibular lymph node enlargement. Her only additional complaint was general
slight asthenia. The patient denied any extramarital sexual relationships. The patient was initially treated
with acyclovir (200mg 5 times per day for 10 days) for presumed herpesvirus infection without beneficial
response.
All laboratory exams including white blood cell count, platelets, hematocrit, protein electrophoresis,
antinuclear antibody, serology for HIV, urinalysis, hepatitis-associated antigen, creatine phosphokinase,
prothrombin time, partial thromboplastin time and C3, C4 were unremarkable. A biopsy with direct
immunofluorescence (DIF) demonstrated a dense inflammatory infiltrate composed of lymphocytes and
plasmocytes with endothelial cell swelling. The DIF was negative. Serologic tests for syphilis revealed the
following results: venereal diseases research laboratory (VDRL) was positive; Treponema pallidum
hemagglutination (TPHA) was positive 1/20,480; fluorescent treponemal antibody absorbed assay (FTAABS) IgG was greater than 1/125; IgM was absent.

Figure 1
Figure 1. Oral serpiginous
erosions with a "snail-track"
appearance and an
erythematous border

Clinical data, histological analysis, and serologic tests led us to the diagnosis of secondary syphilis. Therefore, we treated the patient with
penicillin G benzathine (1.2 mU each week for 3 weeks) associated with betamethasone (4 mg IM each week for 2 weeks) to avoid JarischHerxheimer reaction. A complete resolution of lesions was obtained within 10 days.
Discussion
Syphilis is a sexually transmitted disease caused by Treponema pallidum infection and manifesting with skin, mucous membrane, and
systemic lesions. This wide array of manifestations has given syphilis the reputation as a great imitator. In the last 20 years there has been a
gradual increase in new cases of syphilis [3].
Typical mucous membrane lesions tend to be oval, serpiginous, raised erosions or ulcers with an erythematosus border. There is an overlying
grey or silver membrane. Sometimes these lesions can appear as leukokeratosis and involve the tongue, the mucosal lip, or the palate. Prior
descriptions suggest that these lesions usually heal within 3-12 weeks regardless of treatment [1, 7].
Usually the spirochetemia of secondary syphilis is associated with systemic symptoms and a cutaneous eruption; rarely there may be
spirochetemia without cutaneous manifestations. The oral cavity is the most common extragenital site of infection, although isolated oral
ulcerations in secondary syphilis are unusual [3]. In fact there are only a few reports of secondary syphilis presenting with isolated oral lesions
[1, 4]. 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].
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18/9/2014

Isolated oral erosions: An unusual manifestation of secondary syphilis [eScholarship]

Lesional histopathology is not diagnostic; histological features of secondary syphilis are very variable, as are the clinical lesions [3, 8].
Endothelial cell swelling, perivascular infiltrates with a preponderance of plasma cells, and epidermal psoriasiform hyperplasia may be
observed.
The differential diagnosis of oral lesions of secondary syphilis includes erythema multiforme, stomatitis, pemphigus, lichen, candidosis, oral
gonorrhoea, and other sexually transmitted diseases [9, 10, 11].
We present our case because of the rare presentation of localized oral lesions of secondary syphilis for 5 months 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.
Syphilis is a highly infectious disease. It is important that clinicians maintain a high clinical index of suspicion and crucial that an accurate
diagnosis be made at presentation.

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