A 26 y.o. male comes to the ED with L groin pain for three days. He works for a moving company.
His CT is shown below. What should be done first?
Vital signs and physical exam should be done first. The patient was febrile. The physical exam ruled out a hernia. A lesion was seen on the shaft of the penis.
Our patient had syphilis. In the secondary stage it can cause fever, hepatitis and rarely, necrotic lymph nodes. Lymph node swelling has been documented in many parts of the body including the lung and cervical nodes.
syphilis can present as tonsillitis
Syphilis was first documented in a European outbreak in 1484 shortly after Columbus returned from the Americas. It was known as the French disease since multiple cases were brought back to France after the French invaded Naples Italy. The bacterium was identified in 1905.
Syphilis is caused by a bacterium (Treponema pallidum) classified under the phylum Spirochaetota. Spirochaetata are distinguished by the helical shape of the bacteria. While several diseases caused by spirochetes are found mainly in tropical areas ( pinta , bejel and yaws), others are found in the US (borrelia and leptospira) . They all present with a mucocutaneous lesion followed by diffuse secondary lesions, a latent period and then late destructive disease.
The course is determined by the immune response. Humoral immunity is antibody-mediated relying on B cells and delayed hypersensitivity is cell-mediated relying on T cells. Delayed hypersensitivity, cell mediated, is the most effective defense with macrophages engulfing and destroying spirochetes.
STAGES OF SYPHILIS
Primary-The initial skin letion is the chancre which is usually a round painless sore where the bacterium first touched the body.
Secondary- A bacteremia occurs in this stage with the appearance of a rash on palms and soles. A widespread vasculitis during secondary syphilis may lead to a broad range of syndromes such as hepatitis, iritis, nephritis, and neurological problems (early meningovascular syphilis) with headache and involvement of the cranial nerves, particularly the auditory nerve. If patients are untreated, a quarter will have relapsing episodes of fever, rash and ulceration.
Latent- in this stage symptoms vanish but the bacteria remain active in the body.
Tertiary or late syphilis- 35% of individuals with latent syphilis develop tertiary syphilis with neurosyphilis with destruction of the dorsal columns, cardiovascular syphilis and gummatous syphilis. Gummas can lead to bone destruction.
tertiary syphilis can erode bone
INTERESTING FACTS
The Tuskegee experiment, in which 600 black men were followed from 1932-1972 with untreated syphilis, yielded almost no useful information since the course of syphilis was already known.
Lenin is thought to have died from syphilis.
Our patient was treated with penicillin and is to be followed in ID clinic.
Komeno Y, Ota Y, Koibuchi T, et al. secondary syphilis with tonsillar and cervical laymphadenopathy and a pulmonary lesion mimicking malignant lymphoma. Am J Case Rep 2016 NE 4L19:238-243.
Davoodi L, Kazeminejad A, Jafarpour H, Razavi A. Leptospirosis presented with erythema nodosum on four limbs: an unusual presentation. Oxf Med Case Reports. 2020 Jan 31;2020(2):omz130.doi:10.1093/omcr/omz130
Trujillo D, Agudelo C, Charvarriaga A, et al. Bone involvement in non=congenital syphilis. Biomedica 2023 Jun 30’43(2):157=163.
French P . Syphilis. BMJ. 2007 Jan29;334(7585):143=147
https://en.wikipedia.org/wiki/List_of_syphilis_cases