C a s e R e p o r t
Syphilis related to atypical oral lesions affecting an elderly man. a case report
Juliane Piragine Araujo
1, Graziella Chagas Jaguar
1and Fabio Abreu Alves
1,21Stomatology Department, Hospital AC Camargo, S~ao Paulo, Brazil;2Stomatology Department, University of S~ao Paulo, S~ao Paulo, Brazil
doi: 10.1111/ger.12047
Syphilis related to atypical oral lesions affecting an elderly man. a case report Objective: To present a case of oral syphilis in an old patient.
Background: Syphilis seems to be resurging mainly in the young. However, in the last twenty years, the elderly have become more susceptive to infectious diseases due to a more frequent use of sildenafil.
Clinical Report: An 83-year-old man was referred to our clinic complaining of burning mouth. His medical history revealed papular lesions on chest and penis glans, which had been diagnosed and trea- ted as scabiosis 2 months prior to our assessment. The intra-oral examination showed erosive and patch lesions on the bilateral lip commissures, the palate and the border of the tongue. Initially, oral herpes was suspected. However, both the serological test and the cytology were negative. Therefore, syphilis was hypothesised. Non-treponemic (VDRL) and treponemic tests (FTA-ABS) were reagent and secondary syphilis was confirmed. The treatment consisted of penicillin G benzathine 2.4 million IU/IM for 4 weeks. Both oral and skin lesions had complete remission.
Conclusion: The present case illustrates that syphilis should be suspected in old patients with oral atyp- ical lesions.
Keywords: syphilis, oral syphilis, oral lesions, oral diseases.
Accepted 6 February 2013
Introduction
Syphilis is a disease caused by Treponema pallidum.
Recently, some studies have shown the resur- gence of syphilis in the world1,2. In Brazil, we also have an increase in the number of reported syphi- lis cases3. Interestingly, this study reports a case of oral syphilis affecting an elderly patient and em- phasises the difficulty of its diagnosis.
Case report
An 83-year-old man, descendant of Japanese immigrants, was referred to our department com- plaining of burning mouth. The medical history revealed maculopapular cutaneous rashes on the trunk of the body and penis glans, which were diagnosed and treated (ivermectin) as scabiosis by a dermatologist. After 2 months, the patient developed oral lesions. Intra-oral examination showed erosive and patch lesions on the bilateral lip commissure, the palate and the border/ventral
surface of the tongue (Fig. 1, a–c). Initially, herpes was suspected, and serological tests and cytology of the lesions were therefore performed. Both examinations presented negative results. Consid- ering such results and the lack of improvement of intra- and extra-oral lesions, the hypothesis of syphilis was suggested and the serological tests were requested. Non-treponemic VDRL (Venereal Disease Research Laboratory test) was positive (titre 1/1024) and treponemic FTA-ABS (Fluores- cent Treponemal Antibody) was reagent. Accord- ing to the clinical features of the lesions and the serological results, secondary syphilis was con- firmed. After diagnosis, the patient was ques- tioned on his sexual life, and reported heterosexual unprotected orogenital sex with multiple partners. Other laboratory tests (HCV, HBs Ag, HBe Ag and HIV) were requested and were negative. The treatment consisted of penicil- lin G benzathine 2.4 million IU/IM a week for 4 weeks. There was total regression of oral and skin lesions after 10 days (Fig. 1, d–f). After
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd,
Gerodontology 2015; 32: 73–75 73
12 months of follow-up (clinical and serological tests), no signs of disease were observed.
Discussion
It is well known that sexually transmitted diseases (STD) are most common in the younger popula- tion. However, the risk of STD has lately increased in the older population due to the advent of effec- tive pharmacotherapy for erectile dysfunction4. Since becoming available in 1998, sildenafil (Via- gra) has been approved to treat erectile dysfunc- tion and quickly gained popularity all over the world5. The increased duration of erection, increased blood flow and subsequent increased mucosal susceptibility may increase the risk of acquiring such infections6. Syphilis is transmitted through sexual intercourse, and the first lesion usually appears in the genital region (chancre), and the treponemes spread through the blood and lymphatic vessels affecting other sites, including the oral cavity2. In the present case, some factors such as patient age and atypical oral lesions made the syphilis diagnosis improbable. Moreover, on his first visit, the patient failed to mention unpro- tected sex and frequent Sildenafil use.
According to the disease status, acquired syphi- lis can be expressed in four stages of occurrence:
primary, secondary, latent and tertiary1. The ini- tial lesion is called hard chancre, which is typi- cally represented by a single large, painless ulcer with an indurate margin often associated with a
painless regional lymphadenopathy. The chancre occurs due to direct contact with an active lesion and heals spontaneously in 4–5 weeks without leaving a scar. The secondary stage develops after 2–12 weeks of the first contact. The cutaneous lesions do not cause pruritus and develop as symmetrical 3–10 mm pink or red macules.
Characteristic anatomical locations are the arms, palms, flanks and soles2. The difficulty in diag- nosing syphilis also occurred because our patient had no regional lymphadenopathy and skin lesions were seen in unusual locations. In addi- tion, the chancre manifested initially in the penis glans, and after 2 months, the skin and oral lesions were observed, being diagnosed as sec- ondary syphilis.
The oral manifestations of secondary syphilis can be extensive and variable without a specific feature. We have recently reported six cases of oral syphilis, and most patients had multiple atyp- ical lesions affecting mainly buccal mucosa, dor- sum of the tongue, palate, lips and retromolar region3. Moreover, secondary syphilis lesions are typically painful and multiple. They occur any- where in the oral mucosa and are usually accom- panied by a concomitant cutaneous eruption7. In the present case, the atypical features of the lesions and the age of the patient made syphilis diagnosis improbable.
In conclusion, oral syphilis should be consid- ered in the differential diagnosis of unusual oral lesions affecting elderly patients.
(a) (b) (c)
(d) (e) (f)
Figure 1 a–c: Oral syphilitic lesions. Erosive and patch lesions on lip commissure (a), palate (b) and ventral surface of the tongue (c). (d–f) Complete healing of the lesions after 10 days of the treatment (penicillin G benzathine).
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 73–75 74 J. P. Araujo et al.
References
1. Compilato D, Amato S, Campisi G. Resurgence of syphilis: a diagnosis based on unusual oral mucosa lesions.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: e45–9.
2. Ficarra G, Carlos R. Syphilis: the renaissance of an old disease with oral implications. Head Neck Pathol 2009; 3:
195–206.
3. Kelner N, Rabelo GD, Perez DEC et al. Analysis of nonspecific oral mucosal and dermal lesions suggestive of syphilis: a report of six cases. Oral Surg Oral Med Oral Pathol Oral Radiol
2012; doi: 10.1016/j.oooo.2012.04.
028.
4. Tan HH, Wong ML, Chan RKW.
An epidemiological and knowledge, attitudes, beliefs and practices study of sexually transmitted infections in older men. Singapore Med J 2006; 47:
886–91.
5. Pfizer Inc. (2010) Viagra Web site.
Available at: http://www.viagra.com/
taking-viagra/viagra-erectile-dysfunc- tion.aspx. (last accessed 9 July 2012).
6. Swearingen SG, Klausner JD. Sil- denafil use, sexual risk behavior, and risk for sexually transmitted diseases,
including HIV infection. Am J Med 2005; 118: 571–7.
7. Junkins-Hopkins JM. Multiple pain- ful oral ulcerations. Secondary syphi- lis. Arch Fam Med 1996; 5: 379–80.
Correspondence to:
Fabio Abreu Alves, Stomatology Department, AC Camargo Hospi- tal, R: Prof. Ant^onio Prudente, 211, 01509-900, S~ao Paulo, Brazil.
Tel.: +55-11-2189-5129 Fax: +55-11-2189-5088
E-mail: falves@accamargo.org.br
© 2013 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd, Gerodontology 2015; 32: 73–75
Oral syphilis in an 83-year-old man 75
