A 53 y.o. woman presents with skin lesions
What might cause them?
these are perianal lesions. Hint: HIV is negative
Our patient had gummas from tertiary syphilis. The name gumma comes from the tendency of the nodules to necrose, which begins in the middle of the lesion where the lesion becomes a slimy stringy mass. Hence the name “gumma”.
Syphilis is caused by a bacterium (Treponema pallidum) classified under the phylum Spirochaets. There are at least three more known species which cause human disease including Treponema pertenue (causing yaws), Treponema carateum( causing pinta) and Treponema pallidum endemicum (causing bejel) Treponema pallidum is the only one which is sexually transmitted.
Yaws is a tropical disease also caused by a spirochete but much less common than syphilis—only 1,000 cases in the US each year.
HOW IS SYPHILIS DIAGNOSED?
Nontreponemal tests –syphilis produces non-spectific antibodies that react to cardiolipin. This is the basis of tests such as the VDRL and RPR. False positive tests are common and occur in pregnancy, malignancy, acute viral infection, HIV, Tbc and autoimmune diseases. After treatment, these tests become negative.
Treponemal tests- these are specific antibodies to T pallidum. They are used to confirm the presence of syphilis when the RPR is positive. FTA-abs is the test commonly used. These tests remain positive for life. There can be false positives in lupus and lyme disease.
STAGES OF SYPHILIS
Primary syphilis is characterized by an ulcer at the site of spirochete inoculation, It occurs 10 to 90 days after exposure.
Secondary syphilis can present in different ways: it is often a rash on the palms and soles. It may present as alopecia syphilitica, moth eaten appearing pattern of hair loss on the scalp or condyloma lata of the perineum. Optic neuritis, hepatitis and uveitis may also develop
Tertiary syphilis can involve mucous membranes and ulcers in these areas my cause destruction of cartilage and “saddle nose”. Tertiary syphilis occurs after decades of infection. Resulting in cardiovascular disease, neurologic findings(tabes dorsalis, cranial nerve abnormalities) or bony lesions(osteitis)
The clinical course of syphilis is determined by the balance between delayed type hypersensitivity and humoral immunity( cytotoxic T cell response) . A strong delayed hypersensitivity is associated with clearance of infecting organisms in a chancre, whereas a strong humoral antibody response is associated with progression to tertiary disease. Tertiary syphilis is very rarely seen in HIV while secondary syphilis is common. .
Our patient was thought to have gummas from tertiary syphilis and was treated with IV penicillin 4 million units q 4 hours for 14 days. Her LP had a negative CSR VDRL but because of deafness in one ear she was thought to have neurosyphilis as well.
He who knows syphilis, knows medicine.
--Sir William Osler
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