Multiple primary syphilis on the lip, nipple–areola and penis: An immunohistochemical examination of Treponema pallidum localization using an anti‐T. pallidum antibody

Abstract

Primary syphilis caused by Treponema pallidum usually develops after sexual contact as an initial solitary sclerosis or hard chancre in the genital region. We describe a case of primary syphilis at three sites in genital and extragenital regions of a man who had sex with men. A 29-year-old man visited our hospital for skin lesions on his lower lip, nipple-areola and penis. A positive syphilis serological test for rapid plasma reagin had a titer of 1:16; the patient also tested positive for specific antibodies against T. pallidum, with a cut-off index of 39.0. Histopathological examination of a nipple-areola biopsy specimen revealed a thickened epidermis and dense infiltration of inflammatory cells extending from the upper dermal layers to the deep dermis. The inflammatory cells were composed of abundant lymphocytes, plasma cells, histiocytes and neutrophils. Immunohistochemical staining for T. pallidum using an anti-T. pallidum antibody showed numerous spirochetes in the lower portion of the epidermis, scattered inside inflammatory cell infiltrate and perivascular sites throughout the dermis. Based on these findings, the patient was diagnosed with primary syphilis. Treatment with oral amoxicillin hydrate was started. Five days after starting treatment, a diffuse maculopapular rash (syphilitic roseola) occurred on his trunk and extremities. Perivascular cuffing due to T. pallidum was present throughout the dermis in the biopsy specimen of a localized lesion of primary syphilis. Moreover, syphilitic roseola, which indicates generalized dissemination of T. pallidum, developed during the course of treatment for primary syphilis. Therefore, we considered perivascular cuffing to be indicative of the dissemination phase.

A Case of Secondary Syphilis with the Extragenital Chancre on the Nipple

“…Syphilis is a sexually transmitted disease caused by Treponema pallidum [1]. e primary-stage of syphilis is mainly characterized by painless ulcers (chancre), which occur mostly in the genitals, anus, oral cavity [2], lips, pharyngeal, and nipple-areola [3].…”

Peculiar clinical presentation of primary syphilis in the oral cavity

“…The erosion is indistinct at the edges, and the tissue in the middle is bright red in color, with a film layer that looks like polish on which the serosity develops, and a base that feels firm when palpated. 7,8 In both cases, the patients had a large ulcer, associated with regional lymphadenopathy, in addition to the absence of lesions involving the genital areas. Because oral ulcers are extremely common, it is important for the dentist to consider chancre in the differential clinical diagnosis of a persistent, non-healing oral ulcer.…”

“…A) Extensive ulceration was observed, covered by a fibrinous membrane, located on the lateral border of the tongue extending from the apex of the base to the ventral surfaces. ; B) The hematoxylin and eosin stain (10x) shows a high population of plasma cells, macrophages and perivascular lymphocytes (blue arrows); C) Immunohistochemical reaction against Treponema pallidum (40x), where many spirochetes were revealed (in brown).Peculiar clinical presentation of primary syphilis in the oral cavity 4 • Clin Lab Res Den 2019: 1-Primary syphilis commonly occurs in the genital region but it can also develop in extragenital regions, including the lips, tongue, palate, conjunctiva, neck, breasts, arms, palms and fingers 7. Oral manifestations of syphilis may represent a diagnostic challenge because of its wide spectrum of clinical appearances 8.…”

An unusual giant serpiginous lesion of secondary syphilis

“… 2 Many clinical manifestations have already been reported, such as annular, nodular, noduloulcerative, (lues maligna), pustular, acneiform, framboesiform, corymbose, photosensitive systemic lupus erythematosus (SLE)-like, leukoderma, pityriasis lichenoides-like and chancriform morphologic patterns. 3 , 4 …”