Unusual clinical manifestation and challenging serological interpretation of syphilis: insights from a case report

Background

The clinical manifestations of recent syphilis can be variable, with typical and atypical patterns. Several conditions may cause atypical clinical aspects, including human immunodeficiency virus (HIV) co-infection. Besides the clinical features, co-infections may completely alter syphilis serological tests, causing interpretative difficulties and diagnostic delays. Aim of the work is to describe the difficulties encountered during the diagnostic evaluation of atypical skin manifestations and of the serology for syphilis of an HIV-infected patient who had contracted it several times.

Case presentation

In 2020, a 52-year old HIV-positive bisexual male patient was admitted to our department with a 4-month history of moderately itchy cutaneous lesions localized at his neck, trunk and arms. In 2013, the patient presented with a classic syphilitic roseola of the trunk and a secondary syphilis was diagnosed, with increased levels of rapid plasma reagin (RPR), Treponema pallidum hemagglutination assay (TPHA), anti-Treponema pallidum IgM and IgG Index. A second episode occurred in 2018, as a primary syphilis with multiple ulcerative lesions of the penis, and increased levels of RPR, IgG and IgM. In 2019, a further episode of secondary syphilis was treated with Doxycycline. In 2020, erythematous and papular lesions with vesicular components and urticarial erythema multiforme (EM)-like lesions were present at the neck, trunk and arms. Serological tests and Nucleic Acid Amplification Test (NAAT) for Treponema Pallidum were performed, as well as a cutaneous biopsy with histological and immunohistochemical evaluation of one lesion. NAAT was negative for T. pallidum. Serological test results were discordant with a new syphilis infection, showing only increased levels of RPR and anti-Treponema IgG. The cutaneous biopsy revealed a non specific histological pattern, while the immunohistochemical evaluation with anti-spirochetal antibodies was mandatory for the diagnosis of recent syphilis, showing clusters of rod-shaped elements, some of which with spiral form, focally present at the epidermis and adnexal structures.

Conclusions

Nowadays, syphilis may present with atypical clinical and serological features. Physicians should be aware of these possible alterations and consider syphilis even in case of uncommon clinical aspect and unclear serological tests. Cutaneous biopsy and immunohistochemical exam may be mandatory for the diagnosis.

Adenocarcinoma of the cervix associated with a neuroendocrine small cell carcinoma of the cervix in the spectrum of Muir-Torre syndrome

Muir-Torre syndrome (MTS) is an autosomal genodermatosis that is diagnosed by the presence of at least one sebaceous gland tumor and at least one visceral malignancy. The most frequent visceral malignancies reported in literature are low-grade colon-rectal and genitourinary cancers, with prolonged survival. The authors report the case of a 52-year-old female, with a positive familial history for MTS, who developed a cutaneous sebaceous carcinoma, a synchronous colon-rectal adenocarcinoma, and a metachronous endocervical adenocarcinoma associated with a neuroendocrine small cell carcinoma of the cervix (SCNC), with lymph node metastasis. The rare occurrence in literature of the cervical SCNC and the rarest occurrence of a neuroendocrine carcinoma in the context of a MTS deviate from the usual and low-grade types of cancers normally described with MTS. It should be always appropriate to assess any symptoms that might reveal an underlying malignancy, although not within the spectrum of neoplasms most associated with this rare syndrome.

Uso dell'analisi d'immagine per la caratterizzazione fenotipica della popolazione asinina Calabrese

Lo studio ha riguardato la caratterizzazione fenotipica di 56 soggetti (tra 2 e 30 anni di età) riconducibili alla popolazione asinina Calabrese, allevati in 23 aziende. Su ciascun soggetto sono stati eseguiti i più significativi rilievi morfometrici mediante l’impiego di un sistema di analisi d’immagine computerizzato. Tali dati sono stati successi-vamente utilizzati per il calcolo dei più significativi indici biometrici. Inoltre sono stati presi in considerazione il colore e le eventuali particolarità del mantello. Gli indici biometrici ricavati ci hanno permesso di inquadrare questa popolazione asinina nel tipo dolicomorfo, come evidenziato dai valori dell’Indice di conformazione laterale del corpo (97,78), dell’Indice toracico di profilo (44,85), dell’Indice di Compattezza (90,80), dell’Indice lunghezza torace (100,79) e dell’Indice di ossatura (12,82). Il colore del mantello è risultato essere principalmente morello (75 %) anche se si è osser-vata la presenza di soggetti baio scuro (20 %) e grigio (5 %). Il colore dell’addome costantemente bianco come anche il muso e le occhiaie. Il colore dell’ano, vulva e mammella è costantemente nero.

Meat quality of buffalo young bulls fed faba bean as protein source

Sixteen Italian Mediterranean Buffalo young bulls were divided into two groups fed isoprotein and isoenergy diets and only differing for protein source of concentrate: faba bean (FB) vs soybean (SB). Animals were slaughtered at 350 kg BW. Meat from FB group showed significantly lower fat, protein, cholesterol and saturated fatty acids than SB group. Significant differences were also found between the three muscles analysed [Longissimus thoracis (LT), Semitendinosus (ST) and Iliopsoas plus Psoas minor (IP)]. ST showed the most favourable fatty acids profile: lower SFA, higher PUFA, MUFA, ω-3, ω-6, CLA and, consequently, lower values for both atherogenic and thrombogenic indexes. Results showed that faba bean can be used as a protein source alternative to soybean in the diet of young buffalo bulls for the production of high quality meat.

Lichen sclerosus and the risk of malignant progression: a case series of 159 patients

AIM AND METHODS

We analyzed 159 stored specimens of Lichen Sclerosus (LS) collected in the period 1999-2011 from 159 patients, in order to evaluate the histological patterns, clinical outcomes and possible associations with malignancies. The histopathologic analysis revealed 145 cases (males and females) with LS alone, 7 in whom penile LS was associated with spinocellular carcinoma (SCC), and 7 in whom LS was associated with a pseudocarcinomatous-hyperplasia (PCH). Extragenital LS was found in 20% (17/85) of the males and 78% (58/74) of the females. In the cases of SCC, immunohistochemical analyses was performed.

RESULTS AND CONCLUSION

The results showed very low positivity to p16INK4A and Ki-67; biomolecular PCR was positive in only two cases, and in both cases the non-oncogenic genotype HPV 100 was detected. No important additional risk factors for malignancies were found (e.g., hormones, infections, other autoimmune diseases).

Preoperative advantages of HF sonography of pilonidal sinus

Pilonidal sinus is a not infrequent disease, probably due to a disontogenetic origin. Histologically, there is a pseudocystic formation in the subcutaneous adipose tissue, containing some hair bulbs. It usually presents a recurring inflammatory course. The pathologic formation does not normally have thick wall, being made up of thin epidermal epithelium, without internal vascularisation and with frequent subcutaneous fistulae. Even though the clinical diagnosis is rather easy, surgery may prove, on the contrary, a demanding task, with a high incidence of recurrence and complications. An adequate knowledge of the condition and its development, with a precise definition of the margins of the lesions, may simplify the surgery, reducing the chance of recurrence or complications. The use of echography in the diagnosis of this disease, in our cohort of 72 patients, has always provided valuable information. In particular, 13 and 18 MHz linear probes and 20 MHz mechanical array have been used, and the latter in particular for the evaluation of fistolous cavities/passageways under the skin. Results. In all our cases, echography has demonstrated pseudocystic formations, without real walls, with fairly high levels of internal echoes, compared to the hair follicles, or, more rarely, true macrocalcifications with one or more cavities/passageways near the skin, without internal vascularisation, according to the histological findings. Echographic data are rapidly obtained, and can prove useful for surgeons for a a better management of patients. Conclusion. We consider diagnostic echography, using high frequency probes, useful for the anatomical definition of this disease, as well as to enable better surgical management.

[The surgical treatment of thin melanoma]

Examination of more than 700 cutaneous melanoma cases, the authors have identified 19 so-called thin melanomas, which have evolved in the long time in metastases. Two tumor distinctive features, vascularization and regression, correlated between them, seem to be particularly important in outlining the future tumor behavior, and so these two parameters must be analysed and included in the histological report. In these cases it is undoubted the need to make a strict surveillance protocol, also more than 10 years. According to our opinion, surgical treatment can immediately provides, in selected cases, the use of sentinel lymph node technique or the integration with other therapies (immuno-treatment).

Morpheaform extra-ocular sebaceous carcinoma

BACKGROUND

Sebaceous carcinoma is an unusual, aggressive, malignant tumor derived from the epithelium of sebaceous glands. It may arise in ocular or extra-ocular sites and is often evident as an ulcerated or non-ulcerated cystic nodule measuring up to 8 cm in diameter. A significant number of extra-ocular sebaceous carcinomas have been associated with metastases and high mortality rate.

METHODS AND RESULTS

We reviewed the literature in the context of our report of a 68-year-old woman who had a morpheaform plaque of the upper lip of 15 years duration, extending into the left naso-genal groove, which histologically also showed marked stromal fibrosis. Three years after excision, there were no signs of recurrence or metastases.

CONCLUSIONS

This patient is unusual in clinical and histologic pattern, as a morpheaform appearance has only been described previously in only one sebaceous carcinoma. In addition, no metastatic disease 15 years after tumor onset is a fortunate and remarkable feature.

Microinvasive squamous cell carcinoma arising on lichen sclerosus of the penis

The case of a 70-year-old white man with a 10-year history of penile lichen sclerosus (LS) who developed microinvasive squamous cell carcinoma on LS is described. A high incidence of penile cancer arising on genital LS has recently been observed. The authors stress the importance of an adequate diagnosis and long-term follow-up in patients with penile LS because of the malignant potential of the disease.

Lipoprotein (a) binds and inactivates tissue factor pathway inhibitor: a novel link between lipoproteins and thrombosis

Lipoprotein (a) [Lp(a)] has been associated with both anti-fibrinolytic and atherogenic effects. However, no direct link currently exists between this atherogenic lipoprotein and intravascular coagulation. The current study examined the binding and functional effects of Lp(a), its lipoprotein constituents, apoliprotein (a) [apo(a)] and low-density lipoprotein (LDL), and lysine-plasminogen (L-PLG), which shares significant homology with apo(a), on tissue factor pathway inhibitor (TFPI), a major regulator of tissue factor-mediated coagulation. Results indicate that Lp(a), apo(a), and PLG but not LDL bound recombinant TFPI (rTFPI) in vitro and that apo(a) bound to a region spanning the last 37 amino acid residues of the c-terminus of TFPI. The apparent binding affinity for TFPI was much higher for Lp(a) (KD approximately 150 nM) compared to PLG (KD approximately 800 nM) and nanomolar concentrations of apo(a) (500 nM) inhibited PLG binding to TFPI. Lp(a) also inhibited in a concentration-dependent manner rTFPI activity and endothelial cell surface TFPI activity in vitro, whereas PLG had no such effect. Moreover physiologic concentrations of PLG (2 microM) had no effect on the concentration-dependent inhibition of TFPI activity induced by Lp(a). In human atherosclerotic plaque, apo(a) and TFPI immunostaining were shown to coexist in smooth muscle cell-rich areas of the intima. These data suggest a novel mechanism whereby Lp(a) through its apo(a) moiety may promote thrombosis by binding and inactivating TFPI.

Evidence of patent ductus arteriosus and right-to-left shunt by finger pulse oxymetry and Doppler signals of agitated saline in abdominal aorta

The diagnosis of patent ductus arteriosus (PDA) with right-to-left shunt in the adult by using transthoracic echocardiography (TTE) is difficult because of limited windows. We report a case of a 23-year-old woman who was referred for treatment of primary pulmonary hypertension but was found to have a PDA with a right-to-left shunt. On examination she had asymmetric hypoxia of the upper extremities on finger pulse oxymetry. Transthoracic echocardiography revealed a large right atrium and no atrial or ventricular septal wall defects. The diagnosis of PDA with Eisenmenger's syndrome was made after evidence of a right-to-left shunt was confirmed by Doppler signals of intravenous agitated saline in the abdominal aorta. This case illustrates the utility of Doppler signals from agitated saline in the abdominal aorta and finger pulse oxymetry, in addition to physical examination, in the diagnosis of PDA with right-to-left shunt.