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1.  Endoscopic Aspects of Gastric Syphilis 
Case Reports in Medicine  2012;2012:646525.
Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.
PMCID: PMC3423921  PMID: 22924047
2.  Diagnosis of Gastric Syphilis by Direct Immunofluorescence Staining and Real-Time PCR Testing 
Journal of Clinical Microbiology  2006;44(9):3452-3456.
We report on a case of gastric syphilis in a patient with chronic dyspepsia. The diagnosis was established by serology and the demonstration of spirochetes in diffusely inflammed gastric mucosa by staining with a fluorescent monoclonal antibody specific for pathogenic treponemes and by the detection of specific treponemal DNA sequences by a real-time PCR.
PMCID: PMC1594693  PMID: 16954299
In a series of more than 200 rabbits in which generalized lesions were observed following local inoculation with Treponema pallidum, there were a number of animals in which characteristic lesions were noted upon mucous membranes or along mucocutaneous borders. These lesions were distributed with about equal frequency between the nose or nasolacrimal system and the eyelids on the one hand, and the genital and anal regions on the other. The lips and buccal mucosa appeared to be less subject to localized infections unless the papillomatous growths noted on the lips and under side of the tongue should prove to be in some way connected with such an infection. In many instances, the local reaction was initiated by an acute inflammatory process, and in the case of nasal and genital infections, a definite exudate was formed. The succeeding stages of the reaction consisted in an infiltration of the parts involved, together with a variable degree of proliferation of fixed tissue cells, leading eventually to necrosis and ulceration. The resulting lesions differed according to their location and the character of the reaction in the individual case. Localized infections of the nose occurred in several forms, first, as a rather diffuse affection of the nasal mucosa characterized by the presence of a mucopurulent exudate, second, as a more or less circumscribed process of infiltration with an especial predilection for the region of the anterior nares, and third, as a granulomatous process involving the alæ in particular. Involvement of the nasal mucosa was very commonly associated with lacrimal overflow and with some degree of conjunctivitis. The lesions of the eyelids were usually small, elevated papules or lesions of an ulcerative character some of which were surrounded by a zone of infiltration. In exceptional instances, large granulomatous lesions occurred along the margins of the lower lids. Infection of the penis and sheath gave rise to conditions analogous to those of the nose. In one group of animals, there was a diffuse affection characterized by redness and swelling of the parts with a mucopurulent exudate, in another there were circumscribed or diffuse infiltrations, while in a third the lesions formed were indurated granulomatous masses. Secondary necrosis with erosion or ulceration was a common feature of all these conditions. Localized infections in the region of the anus differed from those in other localities chiefly in the absence of an exudative group of affections and in the frequency with which lesions of a papillomatous type occurred. Lesions of mucous membranes and mucocutaneous borders developed at periods of time varying from a few weeks to several months after inoculation. Most of them were rather enduring and in several instances persisted in an active condition for considerably more than a year.
PMCID: PMC2128283  PMID: 19868457
4.  Case of Secondary Syphilis Presenting with Unusual Complications: Syphilitic Proctitis, Gastritis, and Hepatitis▿ 
Journal of Clinical Microbiology  2011;49(12):4394-4396.
We report the first known case of syphilis with simultaneous manifestations of proctitis, gastritis, and hepatitis. The diagnosis of syphilitic proctitis and gastritis was established by the demonstration of spirochetes with anti-Treponema pallidum antibody staining in biopsy specimens. Unusual manifestations of secondary syphilis completely resolved after 4 weeks of antibiotic therapy.
PMCID: PMC3233005  PMID: 21998411
From the study of a large series of rabbits with outspoken manifestations of generalized syphilis, lesions of the skin and appendages were found to constitute one of the largest and most varied groups of such affections. The conditions noted consisted of alopecias, onychia and paronychia, and lesions of the skin proper. It was found to be a matter of some difficulty to make a positive diagnosis of syphilitic alopecia, but there were three and possibly four conditions which appeared to be attributable to such an infection. The first of these took the form of a general or local roughening of the coat with falling of the hair which produced the typical moth-eaten appearance associated with syphilitic alopecia in the human subject. A second form of alopecia was essentially an abnormal looseness of the hair which permitted large areas of the body to be completely denuded. The third type of alopecia was associated with definite skin changes, and the hair was readily removable together with an adherent mass of epithelial scales. Paronychia was comparatively rare but was readily recognized by a characteristic infiltration and exfoliation of the skin about the base of the nails. The incidence of onychia is uncertain. Late in the course of the investigation it was found that alterations in the nails which were not entirely characteristic in themselves might occur in consequence of a syphilitic involvement of the nail beds which could not be detected by ordinary methods of examination. The cases which were recognized as syphilitic were those which showed an associated paronychia. Lesions of the skin were found to be one of the most frequent manifestations of a generalized infection in the rabbit. These lesions were divided into three classes: first, granulomatous lesions, second, infiltrations, and third, erythemata. The granulomata were lesions of a fleshy character which tended to grow to a very large size and presented all the characteristics of circumscribed primary lesions of the scrotum. The conditions described as cutaneous infiltrations included two general types of lesions, one a flattened and rather diffuse process, the other an elevated and sharply circumscribed papule. As a class, these lesions were very prone to secondary alterations and in this way gave rise to a great variety of conditions which in general resembled the diffuse primary lesions of the scrotum and the papular lesions resulting from local dissemination. A third type of lesion resembling the macular erythemata of man was observed in a small number of animals, and while no definite proof of the specific origin of these lesions was obtained, the evidence available was strongly suggestive. In addition, several other cutaneous affections were noted which have not as yet been thoroughly investigated. It is suggested, however, that these processes may bear some relation to infection with Treponema pallidum.
PMCID: PMC2128292  PMID: 19868455
6.  Progressive painless lower limbs weakness in a dialyzed patient: undiagnosed tertiary syphilis: a case report 
Cases Journal  2010;3:23.
Syphilis is a sexually transmitted disease, remaining under-estimated, under-recognized due to the variability of clinical presentation and ageing of the population with chronic comorbidities. Hence, some manifestations of the past are nowadays superimposed on the course of chronic diseases. Clinical suspicion should be guided by past medical history of contracting any other sexual disease in a heterosexual person or man who has sex with man.
Case presentation
We describe a rare case of tertiary syphilis in a hemodialyzed diabetic patient whom was career of chronic liver disease due to the evolution of chronic hepatitis B virus infection complicated by a hepatocellular carcinoma. Initial orientation in diagnosing this rare presentation of progressive painless lower limbs weakness was attributed to possible side effects of ongoing anti viral therapy including lamivudine and adefovir. We continued administering both drugs while patient notified a spectacular improvement under Ceftriaxone therapy introduced empirically for a possible chest infection. Routine ophthalmologic examination realized in a teaching hospital, scheduled without knowing the course of late infection showed the presence of a syphilitic uveitis.
This case emphasizes the need for a high index of clinical suspicion for syphilis before the occurrence of symptoms related to its end organ damage dominated by neurosyphilis form. Early diagnosis is the key to preventing significant morbidity and mortality and improving prognosis. However, in the setting of chronic diseases such as chronic kidney diseases either before setting up methods of renal replacement therapy or under immune-suppressive therapy; clinical presentation might resemble any disease, delaying the certitude of the diagnosis by prescribing a rapid plasma reagin.
PMCID: PMC2836290  PMID: 20180955
7.  Increased risk of gastric adenocarcinoma after treatment of primary gastric diffuse large B-cell lymphoma 
BMC Cancer  2013;13:499.
There have been sporadic reports about synchronous as well as metachronous gastric adenocarcinoma and primary gastric lymphoma. Many reports have dealt with metachronous gastric adenocarcinoma in mucosa-associated lymphoid tissue lymphoma of stomach. But to our knowledge, there have been no reports that document the increased incidence of metachronous gastric adenocarcinoma in patients with gastric diffuse large B-cell lymphoma. This retrospective study was conducted to estimate the incidence of metachronous gastric adenocarcinoma after primary gastric lymphoma treatment, especially in diffuse large B-cell lymphoma.
The retrospective cohort study of 139 primary gastric lymphoma patients treated with radiotherapy at our hospital. Mean observation period was 61.5 months (range: 3.7-124.6 months). Patients profile, characteristics of primary gastric lymphoma and metachronous gastric adenocarcinoma were retrieved from medical records. The risk of metachronous gastric adenocarcinoma was compared with the risk of gastric adenocarcinoma in Japanese population.
There were 10 (7.2%) metachronous gastric adenocarcinoma patients after treatment of primary gastric lymphomas. It was quite high risk compared with the risk of gastric carcinoma in Japanese population of 54.7/100,000. Seven patients of 10 were diffuse large B-cell lymphoma and other 3 patients were mixed type of diffuse large B-cell lymphoma and mucosa associated lymphoid tissue lymphoma. Four patients of 10 metachronous gastric adenocarcinomas were signet-ring cell carcinoma and two patients died of gastric adenocarcinoma. Metachronous gastric adenocarcinoma may have a more malignant potential than sporadic gastric adenocarcinoma. Old age, Helicobacter pylori infection and gastric mucosal change of chronic gastritis and intestinal metaplasia were possible risk factors for metachronous gastric adenocarcinoma.
There was an increased risk of gastric adenocarcinoma after treatment of primary gastric lymphoma, especially of diffuse large B-cell lymphoma.
PMCID: PMC3816307  PMID: 24159918
Gastric lymphoma; Metachronous gastric adenocarcinoma; Diffuse large B-cell lymphoma; Radiotherapy
8.  Congenital syphilis, still a reality 
Congenital syphilis is a potentially serious pathology affecting newborns of infected mothers. Even one case of congenital syphilis is a sentinel public health event, since timely diagnosis and treatment of syphilis infected pregnant woman should prevent transmission almost entirely. Here, we are reporting a case of early symptomatic congenital syphilis presented with severe desquamating papulosquamous lesions over multiple body parts along with erosive lesions around oral cavity and nostrils.
PMCID: PMC3730478  PMID: 23919058
Congenital syphilis; treponema pallidum; venereal disease research laboratory
9.  Case Report: Neuropathic Arthropathy of the Hip as a Sequela of Undiagnosed Tertiary Syphilis 
Neuropathic arthropathy is characterized by rapidly progressive bone destruction in the setting of impaired nociceptive and proprioceptive innervation to the involved joint. It is seen most commonly in the foot and ankle, secondary to peripheral neuropathy in patients with diabetes mellitus. Other less common sites of involvement may include the knee, hip, shoulder, and spine, depending on the underlying etiology. Neuropathic arthropathy can be associated with tabes dorsalis, a unique manifestation of late, tertiary neurosyphilis that may arise in individuals with untreated syphilis many years after initial infection, and usually involves the knee, or less commonly, the hip.
Case Report
We report the case of a 73-year-old man with neuropathic arthropathy of the hip and tabes dorsalis attributable to previously undiagnosed tertiary syphilis. There was considerable delay in the diagnosis and unnecessary diagnostic testing owing to failure to consider syphilis as the cause.
Literature Review
With the advent of effective antimicrobial therapy and public health campaigns, the relationship between untreated syphilis and neuropathic arthropathy has been primarily a historic point of interest. However, current epidemiologic research suggests a resurgence of syphilis in the United States, with an increased incidence of patients presenting with manifestations of tertiary syphilis from unidentified and untreated primary infections. Treatment options for neuropathic arthropathy of the hip are limited. Arthrodesis has had poor success and treatment with THA has had high complication rates.
Syphilis is not merely a historic cause of neuropathic arthropathy. Neurosyphilis and tabes dorsalis should be considered in the differential diagnosis for patients presenting with rapid joint destruction consistent with Charcot arthropathy and no other apparent cause.
PMCID: PMC2947698  PMID: 20151233
10.  John Hunter's alleged syphilis 
The allegation that John Hunter suffered from syphilis is challenged. It is suggested that he was the subject of non-luetic vascular disease, evidence for which may be found by a study of his symptoms and autopsy report. It is further suggested that John Hunter's famous inoculation experiment was performed not on himself but on another subject. It is claimed that there is in fact no scientific evidence for attributing John Hunter's illness to syphilis and it is urged that the stigma of this diagnosis should be expunged from his image.
PMCID: PMC2491756  PMID: 324336
11.  Gastritis cystica profunda recurrence after surgical resection: 2-year follow-up 
Gastritis cystica profunda (GCP) is an uncommon disease characterized by multiple cystic gastric glands within the submucosa of the stomach.
Case description
Here, we present a case of a 63-year-old man with intermittent epigastric discomfort in whom gastroscopy revealed multiple irregular elevated nodular lesions with smooth surfaces at the anterior of the antrum. Surgical resection of the nodular lesions was performed, and the diagnosis of gastritis cystica profunda (GCP) was confirmed by histological examination. Another elevated nodular lesion approximately 10 mm in diameter with an ulcer was found on the gastric side of the remnant stomach near the resection side from 6 to 24 months after the surgical resection. Endoscopic ultrasonography (EUS) and repeated biopsies of the new elevated lesion were performed. Homogeneous, anechoic masses originating from the submucosa without gastric adenocarcinoma in histological examination showed GCP recurrence may occur.
We report a case of GCP recurrence within 6 months after surgical resection. GCP should be considered in the differential diagnosis of elevated lesions in the stomach.
PMCID: PMC4030027  PMID: 24885818
Gastritis cystica profunda; Gastric cancer; Endoscopic ultrasonography
A study was made of the infections produced in rabbits inoculated in the testicles with two strains of Treponema pallidum which had been carried in rabbits for several years. Infection resulted in all instances; the incubation period varied as a rule between 2 and 6 weeks and under properly chosen conditions could be reduced to approximately 3 weeks or less. The resulting infection pursued a typically cyclic or relapsing course which affected both the spirochetes and the associated lesions in the testicle. The spirochetes in the local lesions exhibited periodic changes less marked and less regular but identical in character with the changes which occur in the blood in cases of relapsing fever. The lesions in the testicle also showed periods of active development and quiescence or regression which followed closely upon the changes exhibited by the spirochetes. The specific reaction in the testicle showed considerable variation in the speed and sharpness with which successive phenomena occurred as well as in the character and extent of the processes themselves. These reactions were of two fundamental types. In one group of animals, the reaction was characterized by an intense cycle of acute exudation and infiltration with a lesser degree of proliferation, followed by crisis and subsequent recurrence of secondary cycles of proliferative reaction of a minor degree. In the other group of animals, the reaction was more chronic in character and consisted largely of infiltration and proliferation. The progress of the reaction was more gradual, and sharp alterations in its course were absent. The infection progressed by a succession of stages with slight and irregular remissions. In a third group of animals, the reaction was subacute, combining at the same time the processes of exudation, infiltration, and proliferation. The first cycle of reaction was fairly acute and terminated in a definite crisis with moderate regression which in turn was followed by recurrence and more or less pronounced secondary cycles of proliferation. In all cases of outspoken infection, there was diffuse involvement of testicle, tunic, epididymis, and cord, but as the infection progressed, the lesions underwent many transformations, so that a variety of lesions was formed from processes which in the beginning were of a common type. Eventually, the reaction became more irregular and the infection became centered in one or more foci which were commonly situated in the epididymis, tunics, scrotum, or mediastinum testis. These centers served as residual foci of infection. The duration of the testicular process was found to be very variable. In some animals, the entire reaction consisted of but a single sharp cycle, and the local infection was terminated by crisis within 4 to 6 weeks after inoculation. As a rule, the period of active infection was from 2 to 4 months, and quiescent or inactive lesions not infrequently lasted for from 4 to 6 months. In exceptional instances, local infection persisted for more than a year.
PMCID: PMC2180204  PMID: 19868411
13.  Gastric obstruction secondary to metastatic breast cancer: a case report and literature review 
Gastrointestinal tract soft tissues metastasis is a well-known occurrence with invasive lobular breast cancer subtypes. Gastric involvement is more common, with reports of both diffuse and localized involvements. Usually, a gastric localized involvement presents as wall thickening with an appearance similar to that of a gastrointestinal stromal tumour; rarely does a localized metastatic deposit grow aggressively to present as a large tumour causing obstructive symptoms. Our case highlights one such unusual presentation in a patient presenting with non-specific gastrointestinal symptoms. To the best of our knowledge, there have been no previous reports on a similar presentation occurring from a localized metastasis.
Case presentation
A 65-year-old Caucasian woman awaiting an outpatient oral gastroduodenoscopy for symptoms of intermittent vomiting, epigastric pains and weight loss of six weeks’ duration presented acutely with symptoms of haematemesis and abdominal distension. An initial contrast-enhanced computed tomography scan showed a grossly dilated stomach with a locally advanced stenosing tumour mass at the pylorus. Our patient had a history of left mastectomy and axillary clearance followed by adjuvant endocrine therapy for an oestrogen receptor- and progesterone receptor-positive, grade 2, invasive lobular breast cancer. The oral gastroduodenoscopy confirmed the computed tomography findings; biopsies of the pyloric mass on immunohistochemistry stains were strongly positive for pancytokeratin and gross cystic disease fluid proteins, consistent with an invasive lobular breast cancer metastasis. She received a palliative gastrojejunal bypass and her adjuvant endocrine treatment was switched over to exemestane.
Our case highlights the aggressive behaviour of a localized gastric metastasis that is unusual and unexpected. Gastrointestinal symptomatology can be non-specific and, at times, non-diagnostic on conventional mucosal biopsies. A high index of clinical suspicion in patients with a previous history of invasive lobular breast cancer can aid in an early diagnosis and treatment. A combined treatment approach with chemoendocrine therapies achieves remission and improves patient survival.
PMCID: PMC3423049  PMID: 22870880
From a study of the reaction to scrotal inoculation with Treponema pallidum in alarge series of rabbits, it was found that the specific reaction presented the following characteristics. In general, the reaction in the scrotum became apparent within 7 to 14 days after inoculation but was subject to considerable variation. The early reaction took the form of an edematous swelling and congestion associated with a new growth of vessels or of an infiltration with more or less proliferation of fixed tissue cells. These reactions were either confined to a small circumscribed area of the scrotum or were of a diffusely spreading character, and as the infection advanced, the infiltration and proliferation together with such secondary changes as exfoliation, necrosis, and ulceration became the most conspicuous features of the reaction. The course of the reaction in the scrotum was essentially the same as that in the testicle; that is, it was periodic in character and was marked by a phase of active progression followed by quiescence or regression and renewed activity. The scrotal reaction resembled that in the testicle also in the varying character of the reaction, appearing at times as a circumscribed focus of reaction and later becoming diffuse, or first as a diffuse reaction which subsequently became more localized. The lesions produced in consequence of this reaction were of two general types —one a circumscribed indurated granulomatous lesion closely resembling the human chancre, the other a diffuse infiltration more analogous to the secondary skin lesions of man. Both groups of lesions presented the greatest degree of individual variations and possessed no fixed status but were subject to frequent and marked transformations. After a period of from a few weeks to many months, the lesions in the scrotum disappeared spontaneously.
PMCID: PMC2128247  PMID: 19868423
15.  Secondary Syphilis in Cali, Colombia: New Concepts in Disease Pathogenesis 
Venereal syphilis is a multi-stage, sexually transmitted disease caused by the spirochetal bacterium Treponema pallidum (Tp). Herein we describe a cohort of 57 patients (age 18–68 years) with secondary syphilis (SS) identified through a network of public sector primary health care providers in Cali, Colombia. To be eligible for participation, study subjects were required to have cutaneous lesions consistent with SS, a reactive Rapid Plasma Reagin test (RPR-titer ≥1∶4), and a confirmatory treponemal test (Fluorescent Treponemal Antibody Absorption test- FTA-ABS). Most subjects enrolled were women (64.9%), predominantly Afro-Colombian (38.6%) or mestizo (56.1%), and all were of low socio-economic status. Three (5.3%) subjects were newly diagnosed with HIV infection at study entry. The duration of signs and symptoms in most patients (53.6%) was less than 30 days; however, some patients reported being symptomatic for several months (range 5–240 days). The typical palmar and plantar exanthem of SS was the most common dermal manifestation (63%), followed by diffuse hypo- or hyperpigmented macules and papules on the trunk, abdomen and extremities. Three patients had patchy alopecia. Whole blood (WB) samples and punch biopsy material from a subset of SS patients were assayed for the presence of Tp DNA polymerase I gene (polA) target by real-time qualitative and quantitative PCR methods. Twelve (46%) of the 26 WB samples studied had quantifiable Tp DNA (ranging between 194.9 and 1954.2 Tp polA copies/ml blood) and seven (64%) were positive when WB DNA was extracted within 24 hours of collection. Tp DNA was also present in 8/12 (66%) skin biopsies available for testing. Strain typing analysis was attempted in all skin and WB samples with detectable Tp DNA. Using arp repeat size analysis and tpr RFLP patterns four different strain types were identified (14d, 16d, 13d and 22a). None of the WB samples had sufficient DNA for typing. The clinical and microbiologic observations presented herein, together with recent Cali syphilis seroprevalence data, provide additional evidence that venereal syphilis is highly endemic in this region of Colombia, thus underscoring the need for health care providers in the region to be acutely aware of the clinical manifestations of SS. This study also provides, for the first time, quantitative evidence that a significant proportion of untreated SS patients have substantial numbers of circulating spirochetes. How Tp is able to persist in the blood and skin of SS patients, despite the known presence of circulating treponemal opsonizing antibodies and the robust pro-inflammatory cellular immune responses characteristic of this stage of the disease, is not fully understood and requires further study.
Author Summary
Venereal syphilis is a sexually transmitted disease caused by the bacterium Treponema pallidum (Tp). We describe 57 patients (age 18–68 years) from Cali, Colombia diagnosed with secondary syphilis (SS). Most were women (64.9%); predominantly Afro-Colombian (38.6%) or mestizo (56.1%), and all of low socio-economic status. Three (5.3%) were newly diagnosed with HIV infection at study entry. The typical palmar and plantar rash of SS was the common clinical finding (63%). Whole blood (WB) samples and skin biopsies were assayed for Tp DNA by using molecular methods. 46% of the WB samples had circulating Tp DNA and 64% were positive when the DNA was extracted on the same day of collection. Tp DNA was also present in the skin of 66% (12/26) of biopsies tested by PCR. We conclude that primary care providers in countries like Colombia need to remain highly vigilant for the clinical presentation of SS. The study also provides, for the first time, qualitative and quantitative evidence that untreated SS patients have significant numbers of spirochetes in blood and skin, and that this occurs despite the known presence of circulating anti-treponemal antibodies and strong cellular immune responses associated with this stage of the disease.
PMCID: PMC2872645  PMID: 20502522
16.  Syphilis: The Renaissance of an Old Disease with Oral Implications 
Head and Neck Pathology  2009;3(3):195-206.
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.
PMCID: PMC2811633  PMID: 20596972
Syphilis; Oral cavity; Treponema pallidum
From a study of a series of rabbits inoculated with two old strains of Treponema pallidum, it was found that localized infection of bones and tendons was of frequent occurrence and led to the formation of a variety of lesions. The bones usually involved were those of the face and the feet and legs. Most often the lesions arose from the periosteum but developed also within the bone or marrow cavities and at lines of epiphyseal union. Grossly, the periosteal lesions were of two types—one being a circumscribed, indurated, and nodular mass and the other a process of a more diffuse character. Histologically, the lesions presented the typical appearance of syphilitic granulomata composed of more or less distinct layers which corresponded roughly with structural divisions of the periosteum. The composition of lesions of membrane and of cartilage bones differed somewhat in this respect, especially in the development of an osteoclastic layer. Invasion of the bone with absorption and necrosis were constant features of periosteal affections and were most marked in the case of the facial bones and the small bones of the feet. Lesions in the bone and marrow cavities were detected chiefly by radiographs or by the occurrence of bone destruction in the absence of periosteal involvement. They were characterized by a loss of structural detail in the bone, rarefication, increased fragility, necrosis, pathological fracture, and epiphyseal separation associated with more or less granulomatous reaction. Histologically, the bone lesions presented essentially the same picture as those of the periosteum, while the lesions which arose from the marrow cavities were composed chiefly of polyblastic infiltrations. In this group of affections, the most important were those which developed at the epiphyses. The destructive effects produced by all classes of lesions varied from a slight surface erosion or rarefication to extensive necrosis resulting in the formation of bony defects or in disintegration or fracture of the bone. These conditions differed very decidedly with the particular bones involved. Of especial importance in this connection was the occurrence of a peculiar form of mass necrosis which at times resulted in the destruction of considerable areas of bone even in parts where the granulomatous type of lesion was comparatively slight. The most characteristic injuries were the saddle-nose deformities and the epiphyseal separation in the small bones of the tarsus and hind feet. The marks of permanent injury were, on the whole, comparatively slight, but they also differed both with the degree of the original injury and with the bone affected. Granulomatous lesions of tendons or tendon sheaths were occasionally seen, and in a few instances, lesions of synovial cavities were demonstrated microscopically.
PMCID: PMC2128201  PMID: 19868512
18.  Acute monoarthritis in a delayed diagnosis of syphilis patient with persistent rupioid psoriasis-like lesions 
BMC Infectious Diseases  2012;12:338.
The incidence of syphilis is increasing in many parts of the world. Clinicians may have limited experience in the diagnosis when the clinical appearance is unusual. If early diagnosis is not made and prompt treatment not given, then the disease may remain quiescent until more serious symptoms or systemic involvement develops.
Case presentation
We report the first case of a delayed diagnosis of syphilis with a ten-year history of persistent rupioid psoriasis-like lesions. Acute monoarthritis and high fever together with aggravation of skin lesions led to a careful clinical examination. Skin biopsies demonstrated syphilis spirochetes on immunohistochemical stain, and syphilis serological titers were positive. Standard treatment with benzathine penicillin brought a partial and transient improvement. A complete clinical and serological resolution of the disease was achieved by a prolonged and repeated penicillin treatment combined with methylprednisolone. A 7-year follow-up of the patient proved a full recovery.
Our case highlights the fact that clinical signs of syphilis can be diverse and complicated. Unusual clinical manifestations can happen in an immunocompetent individual. Treatment strategy may need to be adjusted in a difficult case.
PMCID: PMC3524466  PMID: 23216913
Syphilis; Monoarthritis; Rupioid psoriasis-like plaque
19.  Cerebrospinal Fluid Abnormalities in HIV-Negative Patients with Secondary and Early Latent Syphilis and Serum VDRL ≥ 1:32 
Syphilis is caused by a spirochete Treponema pallidum. Invasion of the central nervous system (CNS) by T. pallidum may appear early during the course of disease. The diagnosis of confirmed neurosyphilis is based on the reactive Venereal Disease Research Laboratory (VDRL) in cerebrospinal fluid (CSF). Recent studies indicated that serum RPR ≥ 1:32 are associated with higher risk of reactivity of CSF VDRL.
The main aim of the current study was to assess cerebrospinal fluid serological and biochemical abnormalities in HIV negative subjects with secondary and early latent syphilis and serum VDRL ≥ 1:32.
Materials and Methods:
Clinical and laboratory data of 33 HIV-negative patients with secondary and early latent syphilis, with the serum VDRL titer ≥ 1:32, who underwent a lumbar puncture and were treated in Department of Dermatology at Jagiellonian University School of Medicine in Cracow, were collected.
Clinical examination revealed no symptoms of CNS involvement in all patients. 18% (n = 6) of patients met the criteria of confirmed neurosyphilis (reactive CSF-VDRL). In 14 (42%) patients CSF WBC count ≥ 5/ul was found, and in 13 (39%) subjects there was elevated CSF protein concentration (≥ 45 mg/dL). 10 patients had CSF WBC count ≥ 5/ul and/or elevated CSF protein concentration (≥ 45 mg/dL) but CSF-VDRL was not reactive.
Indications for CSF examination in HIV-negative patients with early syphilis are the subject of discussion. It seems that all patients with syphilis and with CSF abnormalities (reactive serological tests, elevated CSF WBC count, elevated protein concentration) should be treated according to protocols for neurosyphilis. But there is a need for identification of biomarkes in order to identify a group of patients with syphilis, in whom risk of such abnormalities is high.
PMCID: PMC3726894  PMID: 23919017
Cerebrospinal fluid examination; early syphilis; neurosyphilis
20.  Syphilis infection among homosexual men reporting contact with syphilis: a case control study 
BMJ Open  2012;2(4):e001339.
High rates of syphilis have been reported among men who have sex with men (MSM) internationally. Guidelines recommend presumptive treatment of sexual contacts of individuals with syphilis at the point of care. The aim of this study was to determine the proportion who were infected with syphilis and the factors predictive of infection among men reporting contact with a man with syphilis.
Contacts who were syphilis infected (cases) were compared with those who were uninfected (controls).
This study was conducted at the main public sexually transmitted diseases clinic in Victoria, Australia.
One hundred and seventy-two MSM presenting as sexual contacts of men with syphilis at a sexual health service in Melbourne, Australia, between July 2007 and October 2011 were assessed for syphilis.
Outcome measures
Proportion of MSM who are infected with syphilis and factors associated with infection.
Of the 172 men who presented reporting contact with syphilis, 26 (15%, 95% CI 10 to 20%) had syphilis. One man had primary syphilis, 4 had secondary syphilis, while the remaining 21 had early latent syphilis. Infection was associated with unprotected anal sex over the prior 3 months (adjusted OR 6.1, 95% CI 1.4 to 26.8).
One in seven men presenting as contacts of syphilis had syphilis infection, most of whom were latently infected. Contacts reporting recent unprotected anal sex were more likely to have syphilis.
PMCID: PMC3425903  PMID: 22907046
Epidemiology -Syphylis; men who have sex with men; partner notification; contact tracing
21.  Performance of the rapid plasma reagin and the rapid syphilis screening tests in the diagnosis of syphilis in field conditions in rural Africa 
Sexually Transmitted Infections  2002;78(4):282-285.
Objectives: To assess the rapid plasma reagin (RPR) test performance in the field and to evaluate a new rapid syphilis test (RST) as a primary screen for syphilis.
Methods: 1325 women of reproductive age from rural communities in the Gambia were tested for syphilis seropositivity using a RPR 18 mm circle card and a RST strip. Within 1 week a repeat RPR and a TPHA test were carried out using standard techniques in the laboratory.
Results: Comparing field tests to a diagnosis of "active" syphilis defined as laboratory RPR and TPHA positive, the RPR test was 77.5% sensitive and 94.1% specific; the RST was 75.0% sensitive and 95.2% specific. The RST was easier to use and interpret than the RPR test especially where field conditions were difficult. In this setting with a low prevalence of syphilis in the community (3%), the chance of someone with a positive test being confirmed as having serologically active syphilis was less than 50% for both tests.
Conclusions: The appropriateness of syphilis screening using RPR testing in antenatal clinics and health centres should be questioned if there is a low prevalence in the population, conditions for testing are poor, and resources limited. There is still an urgent need for an appropriate rapid syphilis test for field use.
PMCID: PMC1744518  PMID: 12181468
22.  Is Congenital Syphilis Really Congenital Syphilis? 
Detroit has recently been distinguished as having the highest congenital syphilis rate in the United States (250.3 cases per 100 000 live births in Detroit versus 10.3 in the US). However, depending on each health department's followup and CDC reporting, these data may not accurately reflect the true congenital syphilis rate. This study examines the reported cases over a three-year time period with focus on the criteria used for diagnosis. All local health department congenital syphilis CDC collection forms (form 73.126) were reviewed for the years in question. The reported congenital syphilis cases in the year 2002–2004 in Detroit were reviewed. No cases met confirmed case criteria and few probable cases were based on neonatal evaluations. The majority of “congenital syphilis” cases were established based on incomplete maternal data such as missing followup serologic titers in the absence of complete neonatal information. In conclusion, although the reported congenital syphilis rate in Detroit is alarmingly high, the true occurrence of congenital syphilis is likely to have been overstated. A health department reporting program that includes more diligent neonatal followup would allow for a more accurate representation of this public health concern.
PMCID: PMC1779614  PMID: 17485812
23.  Congenital syphilis after treatment of maternal syphilis with a penicillin regimen exceeding CDC guidelines. 
BACKGROUND: Although congenital syphilis usually occurs as a result of a failure to detect and treat syphilis in pregnant women, failures of the currently recommended regimen to prevent congenital syphilis have been reported. CASE: This report describes an infant with congenital syphilis despite maternal treatment with a regimen exceeding current CDC guidelines. CONCLUSION: Regardless of the regimen used to treat syphilis during pregnancy, clinicians should recognize the possibility of occasional treatment failures and the importance of adequate follow-up of infants at risk for congenital syphilis.
PMCID: PMC1784788  PMID: 9785110
24.  Early prenatal syphilis 
Syphilis in pregnancy still remains a challenge despite the availability of adequate diagnostic tests for serological screening and penicillin therapy. We report a case of 2 month old female infant who presented with runny nose, papulosquamous lesions over both palms and soles and perianal erosions since 1 month after birth. Cutaneous examination revealed moist eroded areas in the perianal region and fine scaly lesions over palms and soles. Radiograph of both upper limbs and limbs revealed early periosteal changes in lower end of humerus and lower end of tibia. Diagnosis of early pre-natal syphilis was confirmed by Child's Serum Rapid Plasma Reagin Antibody test [S.RPR] being positive with 1:64 dilution while that of mother was 1:8.
PMCID: PMC3481403  PMID: 23130193
Prenatal syphilis; serological screening
25.  Early Syphilis: A Cause of Mono-Arthritis of the Knee 
The number of syphilis cases has increased in the UK in recent years, but many clinicians have limited experience in the diagnosis and treatment of this disease. If early diagnosis is not made and treated promptly with antibiotics, the disease may remain latent until the more serious manifestations of tertiary syphilis develop. We present the case of a 27-year-old man who presented with an acute mono-arthritis secondary to syphilis. The condition responded to antibiotic therapy. Orthopaedic surgeons should be aware of the diagnosis and consider it in patients with an acute arthropathy.
PMCID: PMC2645748  PMID: 18634719
Knee; Syphilis; Mono-arthritis

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