原文題目

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口腔病理科 On-Line KMU Student Bulletin

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原文題目(出處)： Oral Syphilis: A Reemerging Infection Prompting Clinicians’ Alertness

原文作者姓名： Sebastian Dybeck Udd, Bodil Lund

通訊作者學校： Department of Oral and Maxillofacial Surgery, Karolinska University Hospital, Stockholm, Sweden Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden 報告者姓名(組別)：曾敬源 Intern K 組

報告日期： 105/06/07

內文：

Introduction

-Syphilis is caused by spirochete bacteria, Treponema pallidum subsp. Pallidum.

-Syphilis presents in three stages denoted as primary, secondary, and tertiary syphilis.

-The primary lesion appears at the site of infection and is characterized by healing ulcers.

-Since the secondary stage is due to systemic spread of the spirochetes beyond the primary infection site, early treatment during primary stage is important.

Oral presentation of syphilis, such as ulceration, mucous patches, and maculopapular lesions

-one-third of the patients proceed into a tertiary stage.

central nervous system like cognitive symptoms, ataxia, and paralysis

Further typical manifestations of the tertiary stage are gumma and generalized glossitis.

-Varying periods of latency may occur between the stages  misdiagnosis

-A cardiovascular syphilis may also occur including aortitis and coronary ostial stenosis with the risk of aneurysm and angina pectoris, respectively.

-T. pallidum 無法培養serology搭配clinical examination診斷。

試驗性療法避免病毒在個體內傳播

若沒有在primary或secondary stage診斷出來長期攜帶疾病的風險致命併發症 Case report

A 53-year-old man seeks a general practitioner at a primary health care clinic with main complaints of sore throat and burning sensation in the pharyngeal area.

1st treatment course:

suspect fungal infectionantifungal medication  2wks no improvement.

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2nd treatment course:

genital rash referred to ENTsuspect fungal infection (not verified by culture)

antifungal treatment, and erythromycin for unclear reason.

3^rdtreatment course:

Two months laterulcers and erythematous lesions of the oral cavity and genital area and emerging rash and red macules on hands, foot soles, and abdominal region

HIV and Chlamydia spp infection was ruled out.

again suspect fungal infection antifungal treatment with the addition of topical cortisone.  stress related.

4^th treatment course:

one month later painful ulcers considered as aphthous-stomatitis stress related was empirically prescribed per oral phenoxymethylpenicillin and denied a referral to a clinic for sexual transmitting diseases (STD), since the diagnosis of aphthous- stomatitis was considered verified.

Another month laterpreviously described symptoms with the addition of dizziness/vertigoAgain the condition was considered to be stress related.

another month latersymptoms including difficulties in memory and perceived affected cognition considered to be stress induced.

Finally:

more than six months after the debut of symptoms

the patient visits the Institute of Odontology at Karolinska Institutet for a regular annual dental examination.

erythematous lesions of the soft palate and ulceration of the left buccal mucosa (Figures 1 and 2).

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After a thorough patient history, including general health and sexual habits, combined with clinical investigation, the tentative diagnosis oral syphilis was suspected.

referred to a STD-clinic: The sample was screened with the specific tests chemilu- minescent microplate immunoassay (CMIA) and confirmed positive with T. pallidum particle agglutination assay (TPPA).

intramuscular injections of benzyl-penicillin and antibody titers were monitored with the unspecific test Venereal Disease Reference Laboratory (VDRL).

Shortly, the patient was totally devoid of disease manifestations and declared free from syphilis.

Discussion

The importance of considering syphilis as a case of oral manifestation of unclear origin

six-month diagnostic delay leads to secondary stage of syphilis

untreated patients in primary or secondary stage of syphilis are considered contagious The diagnostic flaws:

1) suspected fungal infection should have been verified by culture

2) before considering psychological, or stress related, causes of a certain condition all other possible physiological explanations should be ruled out.

Antibiotics were prescribed twice without clear indications. Although such treatment may by chance be correct, the patient is likely to be reinfected because lack of diagnosis prevents the index patient from being detected. Thus, in the current case, repeated reinfection cannot be ruled out, which emphasizes the importance of diagnoses prior to antibacterial treatments.

biopsy based diagnostics is not reliable: routine histologic appearance of syphilis infected tissue is mainly an unspecific inflammatory reaction.

The first choice for such conditions is often corticosteroid which might trigger acute exacerbation of the infection. The extensive periods of latency that may occur can give the false impression of successful treatment.

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In conclusion, in patients with ambiguous oral manifestations, oral syphilis should be ruled out and preferentially the patient should be referred to a physician well trained in infectious diseases.

題號題目

1 下列何者最不可能是 primary stage of syphilis 發生 chancre 處？

(A)口腔 (B)四肢 (C)肛門 (D)生殖器

答案(B ) 出處：Oral and Maxillofacial Pathology, 3e p188

題號題目

In 1858, Sir Jonathan Hutchinson described the changes found in congenital syphilis and defined the following three pathognomonic diagnostic features, known as Hutchinson’s triad:

Which of the following is not included?

2 (A) Hutchinson’s teeth

(B) Ocular interstitial keratitis (C) Eighth nerve deafness (D) Gumma

答案(D ) 出處：Oral and Maxillofacial Pathology, 3e p190