Syphilitic Osteitis in a Patient with Secondary Syphilis and Concurrent Human Immunodeficiency Virus Infection

Abstract

Destructive bone disease is a well-recognized complication of congenital and tertiary syphilis. Clinically significant osteitis and osteomyelitis are rare complications of primary or secondary syphilis in patients who are not infected with human immunodeficiency virus (HIV). We report a case of an HIV-infected man who presented with symptomatic, left ulnar osteitis as the initial manifestation of secondary syphilis. The patient's clinical course was complicated by a pathological fracture, but he responded to high-dose intravenous penicillin G therapy and surgical intervention. Results of physical examination on follow-up at 15 months were normal, and a serofast (rapid plasma reagin [RPR]) titer of 1:4 and a markedly decreased uptake on bone scintigraphy were observed. Our case report suggests that bone disease can represent an atypical manifestation of early acquired syphilis and that HIV-positive patients who present with orthopedic complaints or bone lesions should be evaluated for the presence of syphilitic bone disease.

Activation and Proteolytic Activity of the Treponema pallidum Metalloprotease, Pallilysin

“…The functional redundancy of host-dependent (thrombin cleavage) and host-independent (autocatalysis) mechanisms of pallilysin activation may enable treponemal dissemination within the diverse host environments the bacterium encounters throughout the course of long-term infection. For example, thrombin levels within the skeletal and nervous systems, which T. pallidum is capable of infecting [15], [52], are significantly lower than levels found within the circulatory system [53].…”

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.…”