原文題目

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口腔病理科 On-Line KMU Student Bulletin

原文題目(出處)： Syphilis related to atypical oral lesions affecting an elderly man. a case report. Gerodontology 2015;32:73-5

原文作者姓名： Araujo JP, Jaguar GCs, Alves FA

通訊作者學校： Stomatology Department, Hospital AC Camargo, University of Sao Paulo, Sao Paulo, Brazil

報告者姓名(組別)：徐瑩 (Intern K 組)

報告日期： 2015/06/09

Abstract：

1. Summary: Syphilis related to atypical oral lesions affecting an elderly man. a case report.

2. Objective: To present a case of oral syphilis in an old patient.

3. 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.

4. 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 treated 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.

5. Conclusion: The present case illustrates that syphilis should be suspected in old patients with oral atypical lesions.

Introduction

Syphilis is a disease caused by Treponema pallidum. Recently, some studies have shown the resurgence of syphilis in the world. In Brazil, we also have an increase in the number of reported syphilis cases3. Interestingly, this study reports a case of oral syphilis affecting an elderly patient and emphasises the difficulty of its diagnosis Case report

1. An 83-year-old man, descendant of Japanese immigrants, was referred to our department complaining 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.

◆剛開始主訴是burning mouth，病史記載有在體幹和陰莖線體表皮有斑丘疹。皮膚科醫生以為是Scabiosis(疥瘡)

2. 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. Considering 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 (Fluorescent Treponemal Antibody) was reagent. According to the clinical features of the lesions and the serological results, secondary syphilis was confirmed.

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◆ 後來因為在兩側唇聯合區， palate 和舌頭邊緣和腹部有 erosive 和 patch lesions，所以懷疑是herpes。

◆serological tests 和 cytology 都是陰性反應，再加上又做了 VDRL 和 treponemic FTA-ABS，都陽性，所以確定是Secondary syphilis。

3. After diagnosis, the patient was questioned 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 penicillin 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 12 months of follow-up (clinical and serological tests), no signs of disease were observed.

Discussion

1. It is well known that sexually transmitted diseases (STD) are most common in the younger population. However, the risk of STD has lately increased in the older population due to the advent of effective pharmacotherapy for erectile dysfunction.

2. Since becoming available in 1998, sildenafil (Viagra) has been approved to treat erectile dysfunction and quickly gained popularity all over the world. The increased duration of erection, increased blood flow and subsequent increased mucosal susceptibility may increase the risk of acquiring such infections.

◆威而鋼因為會增加血液流速和，進而導致黏膜更容易有這種感染

3. 介紹四型梅毒：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 cavity. 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 unprotected sex and frequent Sildenafil use.

4. According to the disease status, acquired syphilis can be expressed in four stages of occurrence: primary, secondary, latent and tertiary. The initial lesion is called

hard chancre, which is typically 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.

◆第一期梅毒：(1) 接觸後 3~90 天發生，傳染力強 (2) chancre(下疳)是其特徵

A. 主要發生在生殖器與肛門附近

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B. 由丘疹，轉為質地堅實，周邊隆起的無痛性潰瘍

C. 少發生在生殖器外區域，但若發生多在 lip

D. 未經治療，可在 4~5 周內自行癒合

5. The secondary stage develops after 2–12 weeks of the first contact. The cutaneous lesions do not cause pruritus(癢) and develop as symmetrical 3–10 mm pink or red macules( 斑 ). Characteristic anatomical locations are the arms, palms, flanks(腰窩) and soles. The difficulty in diagnosing syphilis also occurred because our patient had no regional lymphadenopathy and skin lesions were seen in unusual locations. In addition, the chancre manifested initially in the penis glans, and after 2 months, the skin and oral lesions were observed, being diagnosed as secondary syphilis.

6. 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 atypical lesions affecting mainly buccal mucosa, dorsum of the tongue, palate, lips and retromolar region. Moreover, secondary syphilis lesions are typically painful and multiple. They occur anywhere in the oral mucosa and are usually accompanied by a concomitant(伴隨的) cutaneous eruption. In the present case, the atypical features of the lesions and the age of the patient made syphilis diagnosis improbable.

◆第二期梅毒：

(1) 接觸後 2~12 周發生，傳染力強

(2) 一般可見頭痛，喉嚨痛，發燒，體重減輕，淋巴腫大

(3) Erythematous rush：瀰漫性的無痛紅斑，會蔓延到首長與腳掌與口腔內 (4) Mucous patches：30%病人在口腔黏膜上會發中央為白色膜狀，且整體突出的病灶

(5) 若伴隨免疫低落的問題，二及梅毒會廣泛蔓延，稱為 Lues Maligna (6) 在 3~12 個禮拜會自行消退，但有時在一年後會復發。

7. In conclusion, oral syphilis should be considered in the differential diagnosis of unusual oral lesions affecting elderly patients.

題號題目

1 何者用的測試抗原來自梅毒螺旋體?

(1)RPR (Rapid Plasma Reagin)

(2)VDRL ( Venereal Disease Research Laboratory) (3) STS (Serologic Tests for Syphilis)

(4) TPHA (Treponema pallidum haemagglutination)

(D) 出處：Dental management of the medically compromised patient p.344 Serologic test for syphilis

題號題目

2 有關梅毒(Syphilis)之敘述，何者錯誤？

(A)其致病原為 Borrelia burgdorferi (B)主要為性接觸傳染之疾病

(C)婦女懷孕時若感染梅毒則可能導致胎兒患有先天性梅毒 (D)一般感染後 2 年內最具傳染性

(A) 出處：Dental management of the medically compromised patient p.341