OralMedicine

Mairad Hayes

David White and Andrea Richards

Secondary Syphilis Presenting as

Atypical Oral Ulceration A Case
Report
Abstract: Syphilis is now regarded by many as being of historical interest only in the aetiology of oral ulceration. Its manifestations are
still often classified as the classical chancre, snail track ulcers and gumma. Recent literature suggests, however, that there has been a
re-emergence of syphilitic ulcers and that these need not fall into the traditional categories. Atypical ulceration with no other apparent
cause should prompt investigations for possible underlying infective causes, such as syphilis, because of the increased incidence of the
disease.
Clinical Relevance: It is important that clinicians maintain a high index of suspicion for syphilis when patients present with atypical oral
lesions and syphilis serology should be part of the routine tests in this situation.
Dent Update 2008; 35: 465467

Syphilis is a sexually transmitted disease
caused by the spirochaete Treponema
pallidum. Recent years have seen a marked
resurgence of the disease, especially in the
western world.1 The resurgence of syphilis
and the public health implications of this
disease,2 suggests that heightened clinical
suspicion should be employed when
investigating ulcers of unknown aetiology.
Syphilis is a disease previously
thought to be close to eradication.2 It is
Mairad Hayes, BDS, MFDS RCS Ed,
SHO, Birmingham Dental Hospital, St
Chads Queensway, Birmingham, B4 6NN,
David White, MB, ChB, FRCP, Consultant
in Genito-Urinary Medicine, Hawthorn
House, Heart of England NHS Foundation
Trust, Birmingham B9 5SS and Andrea
Richards, BDS, MSc, FDS RCS, FDS(Oral
Med) RCS, Consultant and Honorary
Senior Lecturer in Oral Medicine,
Birmingham Dental Hospital, St Chads
Queensway, Birmingham, B4 6NN, UK.
September 2008
highly infective, especially in the primary
and secondary stages, and a limited risk
of infection in the early latent stage has
also been reported.2 Therefore, the global
implications of its resurgence cannot be
ignored. Additionally, the lesions of early
syphilis can heal spontaneously, even when
inappropriate treatment is given. Accurate
diagnosis and suitable treatment at initial
presentation are therefore imperative to
limit further spread.1
Syphilis is classically
represented by three defining clinical
presentations, namely:
The chancre of primary syphilis;
The snail track ulceration of secondary
syphilis; and
The gumma of tertiary syphilis.
However, syphilis as a clinical
entity is often referred to as the great
imitator, with numerous and varied
complex manifestations.3 It is this
characteristic which underlines the
relevance of including syphilis in the
differential diagnosis for atypical ulceration
so as to ensure appropriate management.
This paper describes a patient
presenting with atypical oral ulceration
unresponsive to widely used medicaments
such as prednisolone mouthwash and
chlorhexidine gluconate mouthwash.
Between initial presentation and his
review appointment three weeks later,
he was seen at a local Genito-Urinary
Medicine clinic where he was diagnosed
with syphilis. Treatment, with penicillin,
led to rapid and complete resolution of
all signs and symptoms, including his oral
ulceration.
This paper aims to provide an
overall review of the typically recognized
oral features of syphilis.
Case report
A 55-year-old man was referred
by his general medical practitioner to
the oral medicine department regarding
painful, persistent oral ulceration of three
months duration. Treatment to date had
included the use of soluble prednisolone
as a mouthwash and chlorhexidine
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 OralMedicine
Figure 1. Atypical oral ulceration.
gluconate mouthwash. Both measures
had failed to eradicate the ulcers or
provide adequate symptomatic relief. He
had also developed a rash on his penis,
which had been treated by his GP with the
application of a cream, but the patient was
unable to provide details of the medication
prescribed.
The patients medical history
included Huntingtons Chorea, which
had been diagnosed 10 years previously,
and cardiac arrhythmia. At the time of
presentation, his medication included
paroxetine for mild depression, and
atenolol.
Examination revealed
widespread oral ulceration affecting the
labial and buccal mucosa, the palate
and the tongue (Figure 1). Some of the
ulcers present were over 1 cm in diameter
and irregular in shape, but others were
confluent. There was no induration. A white
slough covered some of the ulcers present.
Initial investigations were a
swab of the ulcers for bacterial and fungal
culture and blood tests, including full
blood count, serum vitamin B12, ferritin,
folate, urea and electrolytes, liver function
tests, random blood glucose and epidermal
antibodies.
The differential diagnosis
included: erosive lichen planus,
medication-induced ulceration, blood
dyscrasia and a vesiculo-bullous disorder.
Initial treatment consisted of
fluticasone proprionate 400 mg per unit
to be used as a mouthwash for up to three
minutes twice daily and nystatin, oral
suspension 100,000 units per ml, 1ml four
times daily for two weeks. Arrangements
were made for review and biopsy three
weeks later.
When reviewed, the oral ulcers
466 DentalUpdate
pg465-467 Secondary syphilis.indd 2
were healing without scarring. The patient
revealed that he had presented himself
to a local Genito-Urinary Medicine clinic
concerned that he might have syphilis.
As well as his oral lesions, he had noticed
haemorrhoids over the same period
and felt tired and unwell. His only sexual
contact in the last year had consisted of
a single oral sexual contact with a man
3 months before. On examination, as
well as his oral lesions, he was found to
have patchy alopecia, condylomata and
a widespread, but faint, macular rash. His
syphilis serology showed very strongly
positive results with a positive syphilis EIA,
a VDRL of 1:128, a TPPA of 1:20480 and
positive IgM. A diagnosis of secondary
syphilis was made and he was treated with
three doses of weekly Benzathine Penicillin
2.4 MIU and made a full recovery.
The results of all investigations
carried out in the oral medicine
department were normal and, at review
two months later, the oral ulcers had
healed. No biopsy was undertaken.
Discussion
The aetiology of syphilis is
either congenital, which is now rarely seen,
or acquired. In acquired syphilis, three
distinct categories are identified, namely
primary, secondary and tertiary syphilis.
Primary syphilis presents 990
days post exposure and typically manifests
in the form of one or more chancres. These
can be on any part of the body and are
not always painless. They are sometimes
mistaken for invasive carcinoma and may
Categories of Syphilis
Primary syphilis
Secondary syphilis
Tertiary syphilis
Table 1. The main oro-facial features of syphilis.
be diagnosed only after biopsy or with a
high index of suspicion.2
Manifestations of secondary
syphilis appear 612 months after
exposure. The manifestations are very
varied but may include:
Localized or diffuse mucocutaneous
ulcers;
Glossitis;
Patchy alopecia;
Generalized lymphadenopathy;
A macular rash often affecting the trunk,
and typically the palms and soles of feet;
Condylomata which resemble fleshy
genital warts may occur and are highly
infectious.2
Up to ten years following
initial exposure, there may be no apparent
clinical manifestations of syphilis, although
the patient can still exhibit positive
serology in the form of tertiary syphilis.
Tertiary or late syphilis is divided into
gummatous syphilis, cardiovascular
syphilis and neurosyphilis.3 Oral lesions
are again very varied but include palatal
perforation and oral leukoplakia. A
comprehensive description of oral and
general manifestations of syphilis is
found in Modern Clinical Syphilology by
Stokes, Beerman and Ingraham, 1944, 3rd
edition.4 The main oro-facial manifestations
of syphilis are outlined in Table 1. Any
clinically suspicious lesions should prompt
referral to local Genito-Urinary Medicine
clinics where appropriate investigations
can be carried out.
The histopathology of syphilitic
lesions is not diagnostic. It is suggested
that the presence of unusual epithelial
Clinical Features
Atypical oral ulceration
Painless tonsillar enlargement
Atypical leukoplakia
Mucocutaneous ulceration
Generalized lymphadenopathy
Rash
Condylomata
Glossitis
Syphilitic leukoplakia
September 2008
5/9/08 11:44:41

hyperplasia, granulomatous or plasma
cell predominant chronic inflammation,
endarteritis and neuritis, are often
indicative of the presence of syphilitic
infection.5
The diagnosis of syphilis
incorporates a series of tests, the more
complex of which may not be available
at some centres. Primary and secondary
syphilis can be diagnosed by dark field
microscopy of skin lesions and direct
fluorescent antibody tests of lesional
exudates but, because of the presence
of commensal spirochaetes, this is
not recommended in the mouth and
serological confirmation is necessary.6
In the UK, enzyme
immunoassays (EIA) utilizing
recombinant antigen produced in
Escherichia coli as a result of DNA
cloning are used as a screening test.1,7
Positive results are confirmed by
T. pallidum specific tests.
Treponemal specific tests
are necessary to confirm a diagnosis of
syphilis. These detect specific antibodies
to T. pallidum and include the T. pallidum
phytohaemaglutination assay (TPPA)
and fluorescent treponemal antibodies
absorbed assay (FTA- Abs).6,8
Non-treponemal tests,
such as the Veneral Disease Research
Laboratory (VDRL) test, detect
antibodies to non-specific treponemal
antigens and reflect disease activity
and monitor follow-up. The non-
treponemal VDRL tests are used to
monitor treatment and follow-up
post treatment.9 The declining titre is
monitored relative to the initial titre, the
stage of infection at commencement of
treatment, treatment and HIV status.1,9
HIV positive patients appear to be less
responsive to treatment for syphilis and,
therefore, all syphilis positive patients
should be tested for HIV.10
Treatment of choice for
syphilis is parenteral penicillin, usually
with prolonged release intramuscular
pencillins such as Benzathine and
Procaine penicillin and the second line
of treatment is doxycycline for patients
allergic to penicillin. Tetracycline,
Erythromycin and Ceftriaxone have also
shown antitreponemal activity.1
There have been interesting
changes in the incidence and
September 2008
pg465-467 Secondary syphilis.indd 3
epidemiology of syphilis in the
United Kingdom. The prevalence
of this sexually transmitted disease
underwent a marked reduction over
the past 60 years after 1940, with the
emergence of penicillin as a widely
available and effective treatment.
Incidence dropped or remained stable
for years until the late 1990s, since
when the incidence has increased
sharply.
Between 1998 and 2000 in
the United Kingdom, the number of
cases of infectious syphilis diagnosed
in men doubled (from 172 to 372)
and rose by 53% (from 102 to 156)
in females.2 During 2000, 48% of
syphilis infections were homosexually
acquired, with highest rates being
recorded in London (2.9/100,000 men;
0.8/100,000 women) and the north-
west of England (2.0/100,000 men;
0.2/100,000 women). Increases in
recent years have tended to occur as
a result of severe localized outbreaks
and have been linked in some
cases to oro-genital transmission.2
Homosexual men, particularly those
with diagnosed or undiagnosed HIV
infection, are a recognized group for
contracting syphilis. In the Birmingham,
UK, area,there do not appear to be any
other clearly defined at risk groups
(personal communication, Dr David
White).
The prolonged course of the
disease, and its many manifestations,
result in syphilis presenting to a
variety of healthcare professionals.
Vigilance is therefore imperative to
avoid misdiagnosis and further spread
of the disease. The oral presentation
may be as asymptomatic disease, overt
ulceration or atypical oral ulceration
and leukoplakia. Syphilis infection
should be considered in the differential
diagnosis of such patients. The highly
infectious early lesions may heal
spontaneously, despite inappropriate
treatment, the patient remaining
infective although assumed to have
been effectively treated.
Alert suspiciousness of
mind, necessary though it may be in
all medical diagnosis, is an absolute
prerequisite to the successful detection
of syphilis. 4
OralMedicine
Conclusion
It is important that
clinicians maintain a high index of
suspicion for syphilis when patients
present with atypical oral lesions,
and syphilis serology should be part
of the routine tests in this situation.
Good communication between health
professionals is needed to control
this disease, which appears to be
undergoing a noticeable resurgence in
society.
References
1. Scott CM, Flint SR. Oral syphilis
re-emergence of an old disease
with oral manifestations. Int J Oral
Maxillofac Surg 2005; 34: 5863.
2. Doherty L, Fenton KA, Jones J et al.
Syphilis: old problem, new strategy.
Br Med J 2002; 325: 153156.
3. Brown DL, Frank JE. Diagnosis and
management of syphilis. Am Acad
Family Physician 2003; 68: 283290.
4. Stokes JH, Beerman H, Ingraham
NR. Modern Clinical Syphilology 3rd
edn. Philadelphia and London: WB
Saunders, 1944.
5. Barrett AW, Villarroel Dorrego M,
Hodgson TA et al. The
histopathology of syphilis of the
oral mucosa. J Oral Pathol Med 2004;
33: 286291.
6. Alam F, Argiriadou AS, Hodgson TA,
Kumar N, Porter SR. Primary syphilis
remains a cause of oral ulceration.
Br Dent J 2000; 189: 352354
7. Gerber A, Krell S, Morenz J.
Recombinant Treponema pallidum
antigens in syphilis serology.
Immunobiology 1997; 196: 535.
8. Young H. Syphilis serology.
Dermatol Clin 1998; 16: 691698.
9. Egglestone SI, Turner AJL.
Serological diagnosis of syphilis.
Commun Dis Public Health 2000; 3:
158162.
10. Doherty L, Fenton K, OFlannagan D.
Evidence for increased syphilis
transmission among homosexual
men and heterosexual women in
Europe. Eurosurveillance Weekly
2000; 4: p.001214. Available at
www.eurosurv.org/2000/01214.
asp
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