Oral syphilis—re-emergence of an old disease with oral manifestations

The Mucosal Manifestations of Syphilis in the Head and Neck

Objectives: Syphilis is a resurging disease which can present itself in many ways, including lesions within the head and neck mucosa. Some of these lesions may clinically mimic oral malignancies. This literature review aims to better characterize the mucosal presentations of syphilis. Methods: PubMed, EMBASE, and clinicaltrials.gov were searched for full-text, English articles published from 1950 to 2022 that reported patients with head and neck mucosal manifestations of syphilis. Articles were screened according to PRISMA guidelines. Results: One hundred forty-three manuscripts documenting 236 individual patients were included in the review. Patients with secondary syphilis accounted for 62% of patients presenting with head and neck mucosal lesions. The most common lesions found in primary and secondary syphilis were ulcerations, primarily found on the tongue, lips, and palate. While serologic studies are the gold standard for diagnosing syphilis, biopsy of these lesions have characteristic syphilitic changes. Conclusions: Syphilis' nickname of "The great imitator" remains to be true, and the head and neck mucosal manifestations of this disease can resemble commonly seen malignancies. Awareness of this disease and its lesions is prudent given the rising incidence of syphilis within the United States.

Annular rupioid secondary syphilis confined to the face

Syphilis is a sexually transmitted infection (STI) caused by treponema pallidum. Its rash usually affects the trunk and limbs extensively, including the palms and soles of the feet. Secondary syphilis confined to the face is extremely rare. We report a case of annular rupioid secondary syphilis, which was misdiagnosed as verruca vulgaris. The patient's lesions were confined to the face and resembled oyster shells. According to epidemiological history, clinical presentation, non-treponemal tests, treponemal tests, and effective benzathine penicillin G treatment, confirmed secondary syphilis.

Syphilitic Chancre of the Lip

Syphilis is a sexually transmitted disease caused by Treponema pallidum. The primary stage of the disease (the chancre) mainly involves the genital areas. Extragenital areas are involved in 5%-14% of cases, many of which occur in the oral cavity. Among the extragenital locations, the lip is the most frequent; however, despite this, published cases of the chancre of the lip are few. We present a case of a chancre presenting on the lip of a nonimmunocompromised 55-year-old male patient with immunohistochemical confirmation.

Sonographic appearance of syphilitic induration mimicking squamous cell carcinoma in the lower lip: a case report

Background

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. Recently, its incidence has been increasing worldwide. We encountered a young woman who presented with induration mimicking squamous cell carcinoma in the lower lip, without major medical conditions.

Case presentation

A 25-year-old Japanese woman presented with a 1-month history of a painless induration in her lower lip. Because squamous cell carcinoma was suspected, a preoperation work up was performed, including laboratory tests, an ultrasonographic examination, and a biopsy. The ultrasonography findings showed an oval-shaped 17 × 11 × 12 mm tumor-like lesion with heterogeneous internal echo and an indistinct border. A pressure test and color Doppler sonography revealed that the lesion was soft with a very abundant blood flow. These findings suggested the possibility of underlying inflammatory causes rather than a neoplastic tumor. Serology tests for syphilis, including the anti-Treponema pallidum antibody and reactive rapid plasma reagin tests, were positive. The biopsy revealed no malignancy. Finally, she was diagnosed as having primary syphilis and treated with amoxicillin for 28 days. The rapid plasma reagin value gradually decreased and the initial induration in her lower lip disappeared.

Conclusion

This case highlights the need for prompt examinations for possible underlying infective causes, such as syphilis, when seeing a painless induration with ulcer in the lip. Ultrasonography was helpful in the differential diagnosis of a tumor-like lesion and should be included in addition to syphilis serology tests, such as anti-Treponema pallidum antibody and rapid plasma reagin tests.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

A Metataxonomic Tool to Investigate the Diversity of Treponema

The genus Treponema contains a number of human and animal pathogenic as well as symbiotic bacteria that are found in vastly different anatomical and environmental habitats. Our understanding of the species range, evolution, and biology of these important bacteria is still limited. To explore the diversity of treponemes, we established, validated, and tested a novel metataxonomic approach. As the informative nature of the hypervariable regions of the 16S rRNA gene differ, we first analyzed each variable region independently. Considering the in silico results obtained, we established and validated the sequencing of the V4-region of the 16S rRNA gene using known mixtures of Treponema species as well as a selected number of clinical samples. The metataxonomic approach was able to identify Treponema to a near-species level. We demonstrate that using a spirochete-specific enrichment, our method is applicable to complex microbial communities and large variety of biological samples. The metataxonomic approach described provides a useful method to unravel the full diversity and range of Treponema in various ecosystems.

Syphilis of the oropharynx: Case series of "The Great Masquerader"

OBJECTIVE

Syphilis is a sexually transmitted infection with various presentations. Although, oropharyngeal manifestations are known to occur, the purpose of this study is to present the first case series in which the lesions were initially mistaken for human-papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A multi-institutional retrospective review.

RESULTS

Six cases of oropharyngeal syphilis were initially thought to be secondary to OPSCC due to presentation. Symptoms were vague and exam findings consisted of either a tonsillar or base of tongue mass, or lymphadenopathy. Biopsies were negative for OPSCC. Further workup diagnosed syphilis, with resolution of symptoms and lesions after antibiotic treatment.

CONCLUSIONS

Head and neck manifestations of syphilis have been reported in the literature. However, this is the first series reporting on oropharyngeal syphilis masquerading as HPV-related OPSCC. Ultimately, otolaryngologists must maintain a high suspicion for syphilis in order to ensure prompt diagnosis and treatment.

Forty cases of acquired oral syphilis and a review of the literature

The aim of this study was to describe 40 cases of acquired oral syphilis (AOS) and to discuss the distribution of demographic characteristics, clinical features, and differential diagnosis of the disease. A retrospective study was conducted covering a 17-year period at a single institution in southern Brazil. Moreover, a literature review was performed through a search of the PubMed database for articles on AOS published between 1955 and March 2018. Data were analyzed descriptively. The predominant group within the case series was male patients in their twenties. The vast majority of cases (92.5%) were in the secondary stage of the disease. The lips were the most commonly affected site, with greyish-white mucous patches and reddish ulcers. In the literature review, the largest number of reported cases came from North America. Male patients in the third and fourth decades of life were most affected. AOS occurred more commonly as mucous patches and ulcers on the tongue and palate. Similarities regarding the distribution by sex, age, and anatomical location were found in the present study when compared to cases reported elsewhere. Clinicians, oral pathologists, and maxillofacial surgeons should familiarize themselves with the variable spectrum of signs and symptoms of AOS in their clinical practice to improve diagnosis and management.

Unusual presentation of secondary syphilis: membranoproliferative glomerulonephritis andmuco-cutaneous lesions

The worldwide re-emergence of secondary syphilis which happened in the last decade, has led to an increase in primary and secondary syphilis cases, along with the presentation of atypical forms. Nevertheless, reports of renal syphilis with mucosal and/or cutaneous manifestations are nowadays increasing. Typically, secondary syphilis infection in adults causes nephrotic syndrome due to a membranous glomerulonephritis. Here, we report a case of a 30-year-old immunocompetent man presenting with skin rash, oral and perianal erosions and nephritic syndrome. Laboratory investigations revealed a form of membranoproliferative glomerulonephritis secondary to Treponema pallidum infection. Therapy with benzathine penicillin brought prompt and complete remission of the disease. Although well described for congenital syphilis, this histopathologic pattern of renal involvement is very rarely reported in adult patients. In case of detection of an otherwise unexplained nephritic syndrome in sexually active patients with mucosal and/or anal lesions, an unrecognized syphilis infection should be suspected.

Secondary Syphilis Presenting as Glossodynia, Plaques en Prairie Fauchée, and a Split Papule at the Oral Commissure: Case Report and Review

Syphilis has been coined "the great imitator" due to its extreme heterogeneity of presentation and mimicry of other conditions. Therefore, it is essential that physicians be familiar with the full spectrum of its manifestations. Syphilis may also lead to oral lesions that, occasionally, are unaccompanied by concomitant tegumentary findings. Such patients will pose unique diagnostic challenges. We report the case of a 45-year-old HIV-infected male patient in whom secondary syphilis presented with burning mouth and dysgeusia that progressed to glossodynia and odynophagia. Examination revealed painful, shallow erosions on the posterior aspect of the tongue, in a pattern of plaques en prairie fauchée. A painful split papule (fausse perlèche or false angular cheilitis) was also present in the left commissure. There were no cutaneous lesions. The oral lesions were considered highly suggestive of secondary syphilis. A novel VDRL assay (which was previously negative) yielded a titer of 1/128. Complete clinical remission was rapidly achieved after initiation of penicillin therapy. A comprehensive review of the literature on oral manifestations of syphilis is offered.

Unusual primary syphilis: Presentation of a likely case with a review of the stages of acquired syphilis, its differential diagnoses, management, and current recommendations

Syphilis is an ancient disease that has re-emerged in the last decade. It is prevalent among men who have sex with men and has increased in incidence with certain ethnic groups. It usually presents as primary or secondary syphilis and can progress to tertiary syphilis if not treated. Primary syphilis will classically manifest as a single, painless ulcer with smooth, clean, and raised borders on the genitals or less often on the oral mucosa. Unusual primary syphilis cases have been reported and can be easily misdiagnosed with a resulting delay of treatment. Secondary syphilis is a systemic disease, wherein the treponemes have disseminated to various organ systems, typically presenting with characteristic mucocutaneous lesions. Tertiary syphilis has a higher rate of morbidity and mortality; as such, the aim of this article is to provide the readers with tools to recognize early syphilis and prevent its progression to late stages. In this review, we present a likely case of unusual primary syphilis mimicking herpes progenitalis as well as a compilation of all atypical cases of primary syphilis from 1973 to 2015. We will also review the differential diagnosis, management, and recommendations for each stage of syphilis.

Systematic review of oral ulceration with bone sequestration

BACKGROUND

This article represents the first systematic review entirely dedicated toward a disease called oral ulceration with bone sequestration (OUBS). We performed this review in order to further define and outline this disease. A secondary interest was to recognize the prevalence and importance of OUBS in relation to other oral disorders accompanied by ulceration and bone exposure.

MATERIAL AND METHODS

The systematic review was registered with PROSPERO (registration number CRD42015024294) and performed in cooperation with Harvard's Countway Library. Searches were built using MeSH terms and proximity operators previously mentioned in OUBS descriptions. Database searches were performed through EMBASE, Medline, and PubMed, followed by a handsearch of bibliographies for relevant articles. Articles were assessed against eligibility and inclusion criteria centering on bone exposure without known etiologic cause. We sought to gather information on patient age, sex, anatomical location, clinical presentation, and comorbidities. PRISMA guidelines were followed.

RESULTS

The searches identified 766 records total. Despite considerable inspection, we found only 8 articles qualifying for our review. In the 8 articles, there were a total of 24 patients fulfilling the criteria of OUBS. Although some abstracts mentioned idiopathic nature, most authors presented clinical cases with probable causes to ulceration and sequestration. The mean age of these patients was 43.21 ± 11.94 years. The male to female ratio was 3:1. The predominant area of occurrence was the mandible (n = 23, 95.8%).

CONCLUSION

The representation of OUBS in the literature remains scarce. More data must be generated and gathered on the concept of OUBS so as to determine the true incidence and importance of this disease. Despite rare occurrences of conditions characterizing OUBS, the recent discussion of this topic in the scientific community calls for more knowledge to be brought forth, with great benefit to patients suffering from ulcerative diseases and osteonecrosis.

Clinicopathologic features, microvessel density, and immunohistochemical expression of ICAM-1 and VEGF in 15 cases of secondary syphilis with oral manifestations

BACKGROUND

Several studies have reported the clinical aspects of oral syphilis, but few papers have considered the involved immunoinflammatory mechanisms.

OBJECTIVE

To analyze the clinicopathologic features and expression of immunoinflammatory and vascular proteins in oral secondary syphilis.

STUDY DESIGN

Fifteen patients with oral secondary syphilis were included; histologic features were analyzed using hematoxylin-eosin-stained histologic slides and immunohistochemical reactions were performed against intercellular adhesion molecule 1 (ICAM-1), vascular endothelial growth factor (VEGF), and CD34.

RESULTS

Lesions presented as multiple plaques and ulcers mostly located on the tongue, lips, and palate. They were covered by a stratified epithelium of irregular thickness showing exocytosis associated with a subjacent plasma cell infiltrate arranged in perivascular and perineural patterns. ICAM-1 and VEGF were expressed on endothelial cells and leukocytes, and microvessel density was similar on the superficial and deep regions of the connective tissue.

CONCLUSIONS

Expression of immunoinflammatory and vascular proteins was intense, suggesting their participation on the pathogenesis of oral secondary syphilis.

Fluorescence in situ hybridization for the identification of Treponema pallidum in tissue sections

Syphilis is often called the great imitator because of its frequent atypical clinical manifestations that make the disease difficult to recognize. Because Treponema pallidum subsp. pallidum, the infectious agent of syphilis, is yet uncultivated in vitro, diagnosis is usually made using serology; however, in cases where serology is inconclusive or in patients with immunosuppression where these tests may be difficult to interpret, the availability of a molecular tool for direct diagnosis may be of pivotal importance. Here we present a fluorescence in situ hybridization (FISH) assay that simultaneously identifies and analyzes spatial distribution of T. pallidum in histological tissue sections. For this assay the species-specific FISH probe TPALL targeting the 16S rRNA of T. pallidum was designed in silico and evaluated using T. pallidum infected rabbit testicular tissue and a panel of non-syphilis spirochetes as positive and negative controls, respectively, before application to samples from four syphilis-patients. In a HIV positive patient, FISH showed the presence of T. pallidum in inguinal lymph node tissue. In a patient not suspected to suffer from syphilis but underwent surgery for phimosis, numerous T. pallidum cells were found in preputial tissue. In two cases with oral involvement, FISH was able to differentiate T. pallidum from oral treponemes and showed infection of the oral mucosa and tonsils, respectively. The TPALL FISH probe is now readily available for in situ identification of T. pallidum in selected clinical samples as well as T. pallidum research applications and animal models.

Unusual case of cervical syphilis with Piringer-Kuchinka-like lymphadenitis

Syphilis rarely presents with cervical lymphadenopathy. We describe a patient with a cervical mass associated with weight loss, asthenia, and night sweats. The mass was excised and histological examination suggested Piringer-Kuchinka lymphadenitis, which is usually present in cervical toxoplasmosis. To the best of our knowledge, Piringer-Kuchinka lymphadenitis has not previously been reported in cervical syphilis.

Oral syphilis: a series of 5 cases

Syphilis is an infectious, usually sexually transmitted, disease caused by Treponema pallidum, subspecies pallidum. Because of the increasing prevalence in Europe during the past few years, dentists could be confronted with patients with oral manifestations of syphilis. Because oral lesions are highly contagious, it is vital to make the correct diagnosis quickly to initiate the proper therapy and to interrupt the chain of infection. We present the cases of 5 patients with syphilis-related oral lesions. These cases are representative because of their clinical presentation, age, and gender distribution and the diagnostic approach. The aim of the present report is to emphasize the importance of the dentist knowing and identifying syphilis in different stages to diagnose the disease and institute treatment at an early stage.

Oral Syphilis: a retrospective analysis of 12 cases and a review of the literature

OBJECTIVE

To present a retrospective analysis of multicentre case series of oral syphilis and a review of relevant literature.

SUBJECTS AND METHODS

A PUBMED search was carried out from 1950 to 2011. Clinical records of patients with exclusive/prevalent oral manifestations of syphilis were collected and examined in three independent hospitals.

RESULTS

Of 23 reports describing 34 patients were detected through the review (35% primary, 56% secondary, and 9% tertiary disease), describing unspecific ulcers (59%), mucosal patches (23%), keratosis (6%), pseudomembranes (3%), and gumma (9%). Multicentre case series revealed 12 patients with oral syphilis, of which 17%, 58%, and 25% with, respectively, primary, secondary, and tertiary lesions. Clinically, patients showed white patches (17%), blistering mucositis (8%), chronic unspecific ulcers with/without skin lesions (50%), gumma (17%), and necrosis of the dorsum of the tongue (8%). Oral bullae and tongue necrosis are never described in the current review.

CONCLUSIONS

Diagnosis of syphilis remains a challenge because of the multiform and polymorphous clinical pattern at onset and its ability to imitate different diseases. It is mandatory to include syphilis in the differential diagnosis of unusual oral lesions. Diagnosis of oral lesions of syphilis is often difficult, and biopsy is required in controversial cases.

Riga-Fede-like disease in a 70 year old woman

Riga-Fede disease (RFD) describes a benign, ulcerative lesion resulting from the repetitive trauma of contact of the oral mucosal surface of the tongue with the teeth. Although the name applies primarily to small children, similar clinical and histopathological findings can also be found in adults. We describe here a 70 year-old woman showing a painful tongue ulcer with elevated borders and whitish discoloration for the past four years. Repeated histological investigations revealed a benign leukoplakia without dysplasia. Replacement of an ill-fitting prosthesis led to complete remission within two weeks. RDF-like disease is thus a problem in elderly patients for whom topical treatment is insufficient to induce healing.

Resurgence of syphilis: a diagnosis based on unusual oral mucosa lesions

BACKGROUND

Known as "the great imitator," secondary syphilis may clinically manifest itself in myriad of ways, involving different organs (including the oral cavity), and mimicking, both clinically and histologically, several diseases, thereby making diagnosis a challenge for clinicians.

CASE REPORT

We highlight an interesting case of a 45-year-old man on whose diagnosis of secondary syphilis was based on the presence of unusual oral lesions, consisting of a well delimited, raised, nonhomogeneous, and corrugated white plaque on the right buccal mucosa which mimicked, clinically and histologically, a "leukoplakia-like" plaque and several whitish oral mucous patches localized on the lower labial mucosa and the right lateral margin of the tongue. After the oral lesions, the patient developed a symmetric maculopapular cutaneous rash on the palms, soles, and the trunk of the body. Furthermore, during the anamnesis the patient stated an asymptomatic ulcerative lesion on the glans penis, which had appeared 7 months before the onset of the oral lesions and spontaneously disappeared after 2 weeks. The history of these genital and cutaneous lesions suggested performing serologic tests for syphilis, revealing strongly positive titers and leading us to making a diagnosis of secondary syphilis.

CONCLUSION

This case is remarkable because it displays an unusual oral sign, associated with secondary syphilis; in fact, only occasionally does syphilis manifest itself with a "leukoplakia-like" plaque. Dentists should consider secondary syphilis in the differential diagnosis of white and/or ulcerative oral lesions, above all in at-risk patients, given the continuing rise of syphilis in western Europe.

Syphilis: the renaissance of an old disease with oral implications

Syphilis is caused by Treponema pallidum an anaerobic filamentous spirochete. In recent years, striking outbreaks have occurred in USA, Canada, Russia, China and some areas of Central and Eastern Europe. Main epidemiology changes reflect sex industry, sexual promiscuity, decreasing use of barrier protection (i.e. condoms) due to false sense of security that nowadays sexually transmitted diseases are curable and lack of pertinent knowledge. Considering that the initial presentation of syphilis may be the oral cavity, it is of great relevance to include this disease in the differential diagnosis of unusual oral ulcerations and white patches. Primary syphilis is a highly infectious disease in which inappropriate treatment may be apparently curative while the patient remains highly infectious. It is then of pivotal importance that clinicians maintain a high clinical index of suspicion. At the present time, clinical-pathologic correlation together with serologic studies remain essential in establishing the diagnosis of syphilis.

Multiple aphthoid syphilitic chancres of the oral cavity

Summary

We describe the case of a 31-year-old man who was affected by three asymptomatic, aphthoid, syphilitic chancres of the oral cavity. These lesions were accompanied by right latero-cervical and chin lymphadenopathy. The infection was previously diagnosed as aphthous stomatitis. The search for Treponema pallidum by means of darkfield microscope examination was positive. The patient was successfully treated with oral erythromycin ethylsuccinate. To our knowledge, this is the first case of multiple aphthoid syphilitic chancres of the oral cavity reported in the literature. We suggest that all patients with a recent history of painless ulcers in the oral cavity, accompanied by regional lymphadenopathy in which the clinical diagnosis has not been confirmed, should undergo a darkfield microscope examination.

[Post syphilitic oro-nasal communication]

INTRODUCTION

Oro-nasal communication occurs due to a lack of bone and mucous membranes between the oral cavity and the nasal fossae, rarely subsequent to tertiary syphilis.

CASE REPORT

A 27 year-old woman with a history of an untreated genital chancre which developed 7 years earlier, presented hard palate necrosis surrounded with granulation tissue. Syphilitic gum of the hard palate was diagnosed. After antibiotic treatment, the palatine lesion healed with persistence of an oro-nasal fistula. Physical examination of the oral cavity demonstrated median oro-nasal communication of the hard palate measuring 0,5 cm in diameter. HIV and syphilitic serologies were negative. The treatment consisted in surgical closure of the oro-nasal communication by the refection of nasal and oral plans. The follow-up was good.

DISCUSSION

Oro-nasal communication due to syphilis is exceptional, of easy diagnosis and generally needs surgical treatment.

Monomorphic Epstein-Barr virus (EBV)-associated large B-cell posttransplant lymphoproliferative disorder presenting as a tongue ulcer in a pancreatic transplant patient

Posttransplant lymphoproliferative disorders are a group of lymphoid proliferations and lymphomas that develop as a consequence of immunosuppression in recipients of solid organ or bone marrow allografts. We describe an unusual oral presentation of posttransplant Epstein-Barr virus-associated diffuse large B-cell lymphoma in a 45-year-old woman after pancreatic transplant.

Syphilis and HIV Infection: an Update

Although once on decline in the United States and Europe, the incidence of syphilis has been on the rise since 2000. This increase is noteworthy because there is a high coinfection rate with HIV, especially among men who have sex with men. In light of high coinfection rates, all HIV-infected patients should be tested for syphilis and vice versa. HIV can alter the clinical manifestations of syphilis and, in turn, syphilis has the potential to change the course and transmission of HIV. This article addresses variations in clinical presentation, diagnosis, and management of individuals coinfected with HIV and syphilis.