Destructive Osteomyelitis Associated with Early Secondary Syphilis in An HIV-Positive Patient Diagnosed by Treponema Pallidum DNA Polymerase Chain Reaction

Abstract

A 20-year old man who had sex with men (MSM) presented with destructive osteomyelitis of the sternal bone and diffuse maculopapular rash. During laboratory evaluation he was found to have secondary syphilis and HIV with viral load of 28,000 copies per milliliter and CD4 count of 251 cells per microliter. Surgical debridement and biopsy of the sternal bone was performed. The biopsy examination demonstrated bone necrosis with perivascular infiltration of plasma cells and lymphocytes and rare hystiocytes. No granulomatous lesions were identified and acid-fast, fungal, silver, and Gram's stains did not show any organism. All cultures were negative. Real-time polymerase chain reaction (PCR) using probes targeting a pathogen-specific and highly conserved TpN47 gene of Treponema pallidum was performed on the DNA, extracted from the biopsy specimen and T. pallidum amplicons were detected. Patient was initially treated empirically with vancomycin, piperacillin/tazobactam and intravenous aqueous penicillin G. After confirming the diagnosis he completed 2 weeks of intravenous aqueous penicillin G treatment with resolution of osteomyelitis confirmed at follow-up visit after 6 weeks. Osteomyelitis is a rarely described manifestation of secondary syphilis. To the best of our knowledge, this is the first case of using T. pallidum DNA PCR to confirm the diagnosis of syphilitic osteitis. We suggest that osteomyelitis may be an underrecognized problem in patients with secondary syphilis, especially in HIV-coinfected individuals and PCR seems to be a valuable method in confirming the diagnosis.

Osteitis in the dens of axis caused by Treponema pallidum

“…During the last decades a number of cases of bone involvement in early syphilis have been reported [10-14]. In these cases the diagnosis has primarily been reached by radiological findings (bone scintigraphy, MRI, x-ray).…”

“…In these cases the diagnosis has primarily been reached by radiological findings (bone scintigraphy, MRI, x-ray). Only one case of syphilitic osteitis where the diagnosis is obtained by PCR technique has been formerly reported [10]. In very few cases spirochetes have been isolated from bone biopsy [3].…”

Challenges in Treating Secondary Syphilis Osteitis in an Immunocompromised Patient with a Penicillin Allergy: Case Report and Review of the Literature

“…Identifying organisms on bone biopsy is inconsistent, with Halm reporting spirochete visualization by dark field microscopy in 50% of biopsied cases of bone involvement with early-stage syphilis [ 18 ]. Varied pathologic findings have been identified, including dense neutrophil infiltration without granuloma formation (Boone et al [ 17 ]), perivascular infiltration with plasma cells and lymphocytes with some necrosis (Gurland et al [ 19 ]), cortical and trabecular bone with attenuated inflammatory infiltrate composed largely of lymphocytes and plasma cells (Huang et al [ 20 ]), bone necrosis with perivascular infiltration of plasma cells and lymphocytes and rare histiocytes (Kandelaki et al [ 21 ]), and acute and chronic osteomyelitis with numerous treponemes seen on silver stain (Kastner et al [ 22 ]).…”

Secondary syphilis resembling erythema multiforme

“…18 Syphilis and HIV may occur as co-infections, broadening the scope of dermatologic and systemic findings in patients with these diseases. 6,19,20 Systemic involvement, including osteitis [21][22][23] and hepatitis, 24,25 may be more aggressive with co-infection. Such patients may also develop an ulcerating secondary syphilis, called lues maligna, or ''malignant syphilis,'' 19,20,26 characterized by ulcerating skin eruptions consisting of dark, crusted pustules, each with an inflamed base.…”