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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.  Gastric Syphilis and Membranous Glomerulonephritis 
Clinical Endoscopy  2015;48(3):256-259.
Syphilis is a chronic systemic infectious disease caused by the bacterium Treponema pallidum. Gastric involvement and nephrotic syndrome are uncommon but well documented complications of syphilis, but the co-occurrence of these two complications in the same patient is extremely rare. Thus, because of their nonspecific presentation, suspicion of gastric syphilis (GS) and nephrotic syndrome is essential for diagnosis. Patients should be investigated thoroughly and a diagnosis made based on clinical, endoscopic, and histological findings, in order to initiate appropriate therapy. We report of a 34-year-old male patient with a history of epigastric pain and a diagnosis of GS and syphilis-associated membranous glomerulonephritis confirmed by gastroscopy and kidney biopsy, who was treated successfully with penicillin G benzathine. This case report provides information on the typical features of GS that should help raise awareness of this rare disease entity among clinicians, resulting in earlier diagnosis and administration of appropriate therapy.
PMCID: PMC4461672  PMID: 26064828
Glomerulonephritis, membranous; Stomach; Syphilis
3.  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
4.  Characteristic waffle-like appearance of gastric linitis plastica: A case report 
Oncology Letters  2014;9(1):262-264.
Linitis plastica is a gastric cancer of diffuse histotype that presents in the fundic gland area, and is characterized by thickening of the stomach wall and deformation of the stomach, resulting in a leather bottle-like appearance. A 66-year-old female was admitted to Kagawa University Hospital (Kagawa, Japan) with epigastric pain. X-ray examination revealed reduced gastric distension and deformation of the stomach, which exhibited a leather bottle-like appearance. Endoscopy indicated a depressed lesion in the gastric antrum, and abnormal folds, which crossed to form a waffle-like appearance in the upper gastric body. Analysis of biopsy specimens from the depressed lesion revealed a poorly differentiated adenocarcinoma. Morphological changes in the gastric folds indicated that the tumor had invaded the upper gastric body, therefore, a total gastrectomy was performed. Subsequent pathological findings demonstrated that the tumor had spread from the primary lesion to the upper gastric body. Therefore, the present report recommends that the diagnosis of the spread of linitis plastica-type gastric cancer should include assessments of the primary lesion, as well as evaluation of morphological changes in the gastric folds.
PMCID: PMC4246919  PMID: 25435971
linitis plastica; scirrhous gastric cancer; diffuse type cancers; signet ring cell adenocarcinoma; waffle-like appearance
5.  Helicobacter pylori infection, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer and early gastric cancer 
AIM: To evaluate the histological features of gastric mucosa, including Helicobacter pylori infection in patients with early gastric cancer and endoscopically found superficial gastritis, gastric erosion, erosive gastritis, gastric ulcer.
METHODS: The biopsy specimens were taken from the antrum, corpus and upper angulus of all the patients. Giemsa staining, improved toluidine-blue staining, and H pylori-specific antibody immune staining were performed as appropriate for the histological diagnosis of H pylori infection. Hematoxylin-eosin staining was used for the histological diagnosis of gastric mucosa inflammation, gastric glandular atrophy and intestinal metaplasia and scored into four grades according to the Updated Sydney System.
RESULTS: The overall prevalence of H pylori infection in superficial gastritis was 28.7%, in erosive gastritis 57.7%, in gastric erosion 63.3%, in gastric ulcer 80.8%, in early gastric cancer 52.4%. There was significant difference (P<0.05), except for the difference between early gastric cancer and erosive gastritis. H pylori infection rate in antrum, corpus, angulus of patients with superficial gastritis was 25.9%, 26.2%, 25.2%, respectively; in patients with erosive gastritis 46.9%, 53.5%, 49.0%, respectively; in patients with gastric erosion 52.4%, 61.5%, 52.4%, respectively; in patients with gastric ulcer 52.4%, 61.5%, 52.4%, respectively; in patients with early gastric cancer 35.0%, 50.7%, 34.6%, respectively. No significant difference was found among the different site biopsies in superficial gastritis, but in the other diseases the detected rates were higher in corpus biopsy (P<0.05). The grades of mononuclear cell infiltration and polymorphonuclear cell infiltration, in early gastric cancer patients, were significantly higher than that in superficial gastritis patients, lower than that in gastric erosion and gastric ulcer patients (P<0.01); however, there was no significant difference compared with erosive gastritis. The grades of mucosa glandular atrophy and intestinal metaplasia were significantly highest in early gastric cancer, lower in gastric ulcer, the next were erosive gastritis, gastric erosion, the lowest in superficial gastritis (P<0.01). Furthermore, 53.3% and 51.4% showed glandular atrophy and intestinal metaplasia in angular biopsy specimens, respectively; but only 40.3% and 39.9% were identified in antral biopsy, and 14.1% and 13.6% in corpus biopsy; therefore, the angulus was more reliable for the diagnosis of glandular atrophy and intestinal metaplasia compared with antrum and corpus (P<0.01). The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis with H pylori-positivity was 50.7%, 34.1%; of erosive gastritis 76.1%, 63.0%; of gastric erosion 84.8%, 87.8%; of gastric ulcer 80.6%, 90.9%; and of early gastric cancer 85.5%, 85.3%, respectively. The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis with H pylori-negativity was 9.9%, 6.9%; of erosive gastritis 42.5%, 42.1%; of gastric erosion 51.1%, 61.9%; of gastric ulcer 29.8%, 25.5%; and of early gastric cancer 84.0%, 86.0%, respectively. The positivity rate of glandular atrophy and intestinal metaplasia of superficial gastritis, erosive gastritis, gastric erosion, and gastric ulcer patients with H pylori positivity was significantly higher than those with H pylori negativity (P<0.01); however, there was no significant difference in patients with early gastric cancer with or without H pylori infection.
CONCLUSION: The progression of the gastric pre-cancerous lesions, glandular atrophy and intestinal metaplasia in superficial gastritis, gastric erosion, erosive gastritis and gastric ulcer was strongly related to H pylori infection. In depth studies are needed to evaluate whether eradication of H pylori infection will really diminish the risk of gastric cancer.
PMCID: PMC4250585  PMID: 15682469
Helicobacter pylori; Glandular atrophy; Intestinal metaplasia; Early gastric cancer
6.  Gastric metastasis from primary lung adenocarcinoma mimicking primary gastric cancer 
Gastric metastases from lung adenocarcinoma are rare. Because gastric metastasis grossly resembles advanced gastric cancer, it is difficult to diagnose gastric metastasis especially when the histology of the primary lung cancer is adenocarcinoma. We describe a case of gastric metastasis from primary lung adenocarcinoma mimicking Borrmann type IV primary gastric cancer. A 68-year-old man with known lung adenocarcinoma with multiple bone metastases had been experiencing progressive epigastric pain and dyspepsia over one year. Esophagogastroduodenoscopy revealed linitis plastica-like lesions in the fundus of the stomach. Pathologic examination revealed a moderately differentiated adenocarcinoma with submucosal infiltration. Positive immunohistochemical staining for thyroid transcription factor-1 (TTF-1) and napsin A (Nap-A) confirmed that the metastasis was pulmonary in origin. The patient had been treated with palliative chemotherapy for the lung cancer and had lived for over fifteen months after the diagnosis of gastric metastasis. Clinicians should be aware of the possibility of gastric metastasis in patients with primary lung adenocarcinoma, and additional immunohistochemical staining for Nap-A as well as TTF-1 may help in differentiating its origin.
PMCID: PMC4357873  PMID: 25780510
Adenocarcinoma of lung; Napsin-A; Thyroid transcription factor-1; Gastric metastasis
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
8.  Canadian Public Health Laboratory Network laboratory guidelines for congenital syphilis and syphilis screening in pregnant women in Canada 
Despite universal access to screening for syphilis in all pregnant women in Canada, cases of congenital syphilis have been reported in recent years in areas experiencing a resurgence of infectious syphilis in heterosexual partnerships. Antenatal screening in the first trimester continues to be important and should be repeated at 28 to 32 weeks and again at delivery in women at high risk of acquiring syphilis. The diagnosis of congenital syphilis is complex and is based on a combination of maternal history and clinical and laboratory criteria in both mother and infant. Serologic tests for syphilis remain important in the diagnosis of congenital syphilis and are complicated by the passive transfer of maternal antibodies which can affect the interpretation of reactive serologic tests in the infant. All infants born to mothers with reactive syphilis tests should have nontreponemal tests (NTT) and treponemal tests (TT) performed in parallel with the mother’s tests. A fourfold or higher titre in the NTT in the infant at delivery is strongly suggestive of congenital infection but the absence of a fourfold or greater NTT titre does not exclude congenital infection. IgM tests for syphilis are not currently available in Canada and are not recommended due to poor performance. Other evaluation in the newborn infant may include long bone radiographs and cerebrospinal fluid tests but all suspect cases should be managed in conjunction with sexually transmitted infection and/or pediatric experts.
PMCID: PMC4353984  PMID: 25798162
Canada; Congenital; Management; Pregnancy; Screening; Syphilis
9.  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
11.  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
12.  Gastric emphysema secondary to laparoscopic gastric band erosion 
Gastric band erosion is a known complication of adjustable gastric band surgery. There are no previous reports of gastric band erosion associated with gastric emphysema (GE) or emphysematous gastritis (EG), a rare condition with a mortality rate exceeding 50%.
We report the first known case of GE found in a 58-year-old lady presenting with acute onset epigastric abdominal pain and haematemesis in the setting of a chronically eroded gastric band. GE was visualised in the anterior gastric wall of the stomach without evidence of EG. Endoscopic and surgical examination of the stomach was undertaken along with band removal followed by defect repair.
GE can result from obstructive, traumatic and pulmonary causes. EG is a rare and often lethal form of GE resulting from bacterial invasion of the gastric wall through a mucosal defect leading to sepsis and gastric necrosis. Early reports documented early definitive operative debridement of necrotic gastric wall of patients with EG while recent reports have demonstrated a feasible non-operative approach among highly selected patients with no evidence of gastric necrosis. There are no previous reports on the treatment of patients with gastric band erosion and suspected EG.
Patients presenting acutely with symptomatic gastric band erosion, radiological evidence of GE with evidence of leucocytosis, peritonism or sepsis may develop EG. A high index of suspicion, low threshold for operative exploration and optimal management with antimicrobial therapy and close supportive care are necessary to ensure the best survival outcomes for these patients.
PMCID: PMC4189050  PMID: 25216194
Gastric emphysema; Emphysematous gastritis; Gastric band; Bariatric surgery; General surgery
13.  The Great Imitator: Ocular Syphilis Presenting as Posterior Uveitis 
Patient: Female, 34
Final Diagnosis: Ocular syphilis
Symptoms: Painful unilateral vision loss
Medication: Benzylpenicillin
Clinical Procedure: Lumbar puncture
Specialty: Infectious Diseases • Ophthalmology
Rare disease
Syphilis is often known as the “Great Imitator”. The differential diagnosis of posterior uveitis is broad with ocular syphilis being particularly challenging to diagnose as it presents similarly to other ocular conditions such as acute retinal necrosis.
Case Report:
A 34-year-old woman with multiple sexual partners over the past few years presented with painful and progressively worsening unilateral vision loss for 2 weeks. Several months prior, she had reported non-specific symptoms of headache and diffuse skin rash. Despite treatment with oral acyclovir for 3 weeks, her vision progressively declined, and she was referred to the university ophthalmology clinic for further evaluation. On examination, there was concern for acute retinal necrosis and she was empirically treated with parenteral acyclovir while awaiting further infectious disease study results. Workup ultimately revealed ocular syphilis, and neurosyphilis was additionally confirmed with cerebrospinal fluid studies. Treatment with intravenous penicillin was promptly initiated with complete visual recovery.
Ocular syphilis varies widely in presentation and should be considered in all patients with posterior uveitis, especially with a history of headache and skin rashes. However, given that acute retinal necrosis is a more common cause of posterior uveitis and can rapidly result in permanent vision loss, it should be empirically treated whenever it is suspected while simultaneous workup is conducted to evaluate for alternative diagnoses.
PMCID: PMC4500594  PMID: 26151369
Eye Infections, Bacterial; Neurosyphilis; Retinal Necrosis Syndrome, Acute; Syphilis; Uveitis, Posterior
14.  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
15.  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
16.  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
17.  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
18.  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
19.  Primary gastric actinomycosis: report of a case diagnosed in a gastroscopic biopsy 
Primary gastric actinomycosis is extremely rare, the appendix and ileocecal region being the most commonly involved sites in abdominopelvic actinomycosis. Herein, we report a case of primary gastric actinomycosis. The diagnosis was made on microscopic evaluation of gastroscopic biopsy specimens. To the best of our knowledge, this is the third case to be reported in the literature, in which the diagnosis was made in a gastroscopic biopsy rather than a resection specimen.
Case presentation
An 87-year-old Saudi male on medication for cardiomyopathy, premature ventricular contractions, renal impairment, hypertension, and dyslipidemia, presented to the emergency department with acute diffuse abdominal pain, abdominal distension, constipation and vomiting for two days, with no history of fever, abdominal surgery or trauma. The patient was admitted to the hospital with an impression of gastric outlet obstruction. Based on radiologic and gastroscopic findings, a non-infectious etiology was suspected, possibly adenocarcinoma or lymphoma. Gastroscopic biopsies showed an actively inflamed, focally ulcerated atrophic fundic mucosa along with fragments of a fibrinopurulent exudate containing brownish, iron negative pigment and abundant filamentous bacteria, morphologically consistent with Actinomyces.
Althuogh extremely rare, primary gastric actinomycosis should be considered in the differential diagnosis of radiologic and gastroscopic diffuse gastric wall thickening and submucosal tumor-like or infiltrative lesions, particularly in patients with history of abdominal surgery or trauma, or those receiving extensive medication. A high level of suspicion is required by the pathologist to achieve diagnosis in gastroscopic biopsies. Subtle changes such as the presence of a pigmented inflammatory exudate should alert the pathologist to perform appropriate special stains to reveal the causative organism.
PMCID: PMC4359583  PMID: 25774092
Actinomycosis; Gastric; Grocott’s; Gram; PAS
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
21.  A Case of Early Gastric Cancer Arising from Gastritis Cystica Profunda Treated by Endoscopic Submucosal Dissection 
Case Reports in Gastroenterology  2014;8(3):270-275.
Gastritis cystica profunda (GCP) consists of hyperplasia and cystic dilatation of the gastric glands extending into the submucosa. It occurs in the residual stomach post surgery and in the unoperated stomach. GCP is considered a benign lesion, but there is controversy about its malignant potential. We report a case of early gastric cancer arising from GCP treated by endoscopic submucosal dissection (ESD) in a 55-year-old unoperated man. Upper gastrointestinal endoscopy revealed a 15-mm diameter submucosal tumor (SMT) in the upper corpus of the stomach. The surface had angiotelectasia and slight depression covered with normal mucosa. Neither ulceration nor erosion was seen. Narrow-band imaging endoscopy showed no abnormalities suggesting gastric cancer. Endoscopic ultrasonography visualized the internally low-echoic SMT, harboring tiny cystic lesions, mainly within the second and third layers of the gastric wall. The SMT was removed by ESD to avoid retention and allow for comprehensive diagnosis. It was diagnosed as GCP with partial well-differentiated adenocarcinoma without involvement of the lateral and deep margins, lymphatic invasion, vascular invasion and perineural invasion. The gastric epithelium comprised normal mucosa without dysplasia. ESD seems to be useful for the diagnosis of SMT, including GCP harboring gastric cancer, and avoids unnecessary surgical procedures.
PMCID: PMC4209264  PMID: 25408629
Endoscopic submucosal dissection; Endoscopic ultrasonography; Gastric cancer; Gastritis cystica profunda; Submucosal tumor
22.  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
24.  18F-fluorodeoxyglucose positron emission tomography/computed tomography findings of gastric lymphoma: Comparisons with gastric cancer 
Oncology Letters  2014;8(4):1757-1764.
The role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in numerous malignant tumors, including gastric lymphoma, is well-established. However, there have been few studies with regard to the 18F-FDG PET/CT features of gastric lymphoma. The aim of the present study was to characterize the 18F-FDG PET/CT features of gastric lymphoma, which were compared with those of gastric cancer. Prior to treatment, 18F-FDG PET/CT was performed on 24 patients with gastric lymphoma and 43 patients with gastric cancer. The 18F-FDG PET/CT pattern of gastric wall lesions was classified as one of three types: Type I, diffuse thickening of the gastric wall with increased FDG uptake infiltrating more than one-third of the total stomach; type II, segmental thickening of the gastric wall with elevated FDG uptake involving less than one-third of the total stomach; and type III, local thickening of the gastric wall with focal FDG uptake. The incidence of the involvement of more than one region of the stomach was higher in the patients with gastric lymphoma than in those with gastric cancer. Gastric FDG uptake was demonstrated in 23 of the 24 patients (95.8%) with gastric lymphoma and in 40 of the 43 patients (93.0%) with gastric cancer. Gastric lymphoma predominantly presented with type I and II lesions, whereas gastric cancer mainly presented with type II and III lesions. The maximal thickness was larger and the maximal standard uptake value (SUVmax) was higher in the patients with gastric lymphoma compared with those with gastric cancer. A positive correlation between the maximal thickness and SUVmax was confirmed for the gastric cancer lesions, but not for the gastric lymphoma lesions. There was no difference in the maximal thickness and SUVmax of the gastric wall lesions between the patients without and with extragastric involvement, for gastric lymphoma and gastric cancer. Overall, certain differences exist in the findings between gastric lymphoma and gastric cancer patients on 18F-FDG PET/CT images, which may contribute to the identification of gastric lymphoma.
PMCID: PMC4156241  PMID: 25202405
positron emission tomography; computed tomography; gastric lymphoma; gastric cancer
25.  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

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