Rare case of Syphilis presenting with oral symptoms: a report

Dr Kaitlyn L. Streight at Baylor College of Medicine, 1 Baylor Plaza, Houston, USA and colleagues have reported a rare case of Syphilis presenting with oral symptoms. The case has appeared in the Journal of Medical Case Reports.

Syphilis is a sexually transmitted bacterial infection of the spirochete, Treponema pallidum. While primary syphilis often involves genitalia, oral manifestations are observed in a subset of patients. These lesions are often associated with submandibular and cervical lymphadenopathy. This is a case report of a primary syphilitic lesion located on the hard palate of the oral cavity, with only a very few cases described previously.

A 59-year-old African American man presented to our emergency department with a 1-month history of progressive submental swelling, subjective fevers, and chills. A review of systems was positive for dysphagia, sore throat, and significant weight loss. He reported a history of genital herpes simplex virus (HSV) infection and explained that he developed a cluster of multiple small, painful blisters on his penis 2 weeks prior to the presentation but denied any other new genital lesions. He also admitted to multiple sexual partners in the past but stated that he had been sexually active with only one female partner during the previous year.

A physical examination revealed marked swelling and tenderness under his mandible and a diffuse erythematous maculopapular rash across his chest with scattered hyperpigmented macular lesions involving his palms and his lower extremities extending to the soles of his feet (Fig. 1). All lesions were nonpruritic and nontender, and he stated that he was unaware of the rash. Further examination revealed a 1 cm × 1 cm nontender ulcerative lesion on the hard palate of his oral cavity (Fig. 2). He was also unaware of this lesion on his hard palate. A genital examination revealed no lesions.

A computed tomography (CT) scan of his head and neck with contrast revealed marked lymphadenopathy from the submental region to his mid-neck with evidence of inflammatory changes and a partially necrotic left submental node.

His white blood cell (WBC) count was 12,500 with a neutrophilic predominance. Rapid plasma reagin (RPR) was reactive with a titer of 1:512. A Microhemagglutination Assay for Treponema pallidum (MHA-TP) was positive. Antigen and antibody tests for human immunodeficiency virus (HIV) infection were negative. Prior to the confirmed diagnosis of syphilis, a core biopsy of a submental lymph node was performed and revealed inflammatory changes with no evidence of malignancy. His cerebrospinal fluid was entirely normal and Venereal Disease Research Laboratory (VDRL) was negative. He received a single dose of 2.4 million units benzathine penicillin G intramuscularly and experienced marked improvement of his malaise and sore throat over the course of the next week. Four months after his initial presentation, repeat RPR titers were 1:8, and he reported complete resolution of his rash, lymphadenopathy, and dysphagia.