Caso Clínico

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A lip ulcer as a first sign of early syphilis in a patient with unknown HIV infection:
a case report

Úlcera labial como signo de presentación de sífilis primaria en paciente con infección por VIH no conocida:
a propósito de un caso

 

A. Pozo Porta¹, I. Iriarte Ortabe², P. Zaballos Diego⁴, M.A. Morey Mas², J. Collado López¹, M.J. Pastor Fortea¹,
I. Forteza-Rey Borralleras³

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Abstract: A case report is presented of a patient with a lip ulcer that led to a primary diagnosis of infection through Treponema pallidum and to a secondary diagnosis of HIV seropositivity. The diagnosis was made by serology and the antibiotic treatment was effective for the syphilis. We conclude that when faced by a lesion of the lip that has an ulcerous appearance, a differential diagnosis should be contemplated that includes a syphilis chancre and, if this is confirmed, the necessary complementary test should be carried out in order to rule out concomitant HIV infection. Key words: Syphilis; Lip ulcer; HIV.

Resumen: Se presenta el caso de un paciente con úlcera labial cuya apariencia clínica simula un carcinoma escamoso. Sin embargo, una correcta historia clínica y la realización de pruebas complementarias conducen al diagnóstico primario de infección por Treponema pallidum y secundario de seropositividad para VIH. Tras el diagnóstico serológico el tratamiento antibiótico es efectivo para la sífilis. Concluimos que ante una lesión labial de aspecto ulceroso debe contemplarse un diagnóstico diferencial que incluya el chancro sifilítico y realizar, en el caso de que se confirme, las pruebas complementarias necesarias para descartar infección concomitante por VIH. Palabras clave: Sífilis; Úlcera labial; VIH.

Recibido: 31 de mayo 2004

Aceptado: 7 de julio 2004

 

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1 Médico residente.
2 Médico adjunto.
3 Jefe de Servicio.
Servicio de Cirugía Oral y Maxilofacial. Hospital Universitario Son Dureta. Palma de Mallorca, España
4 Médico adjunto. Servicio de Dermatología. Hospital de Santa Tecla, Tarragona, España

Correspondencia:
A. Pozo Porta
c/ Andrea Doria 55.
07014 Palma de Mallorca, España.
E-mail: albertpozoporta@hotmail.com

 

Introduction

Syphilis has reappeared over the last years in conjunction with the Human Immunodeficiency Virus (HIV). This should therefore be taken into account with regard to oral lesions, as the oral cavity is the first extragenital location in Treponema pallidum infection, together with the possibility of atypical manifestations, given that infection by the HIV virus can affect the natural course of syphilis and even the response to treatment.

The case presented is aimed at highlighting the diagnosis of Treponema pallidum infection based on a lip lesion and how this should serve as a sign for further study in order to confirm the secondary diagnosis of HIV infection. It shows the importance of a differential diagnosis of this lesion that includes squamous cell carcinoma of the lip and herpes infection.

Case Report

A 38-year-old male was sent to the Emergency Unit by his doctor for an evaluation of a lesion on his lower lip that had been evolving for a month and a half.

His personal background included: undetermined hepatitis, a tonsillectomy during his youth, and a homosexual habit.

For a month and a half the patient had noticed the appearance of a lesion on his lower lip that had improved partially with the acyclovir treatment prescribed by his GP, but that worsened on stopping it. The patient also referred to lesions on the scrotum and left foot that had appeared recently.

The physical examination revealed an ulcerated lesion measuring 2 cm on the left side of the lower lip vermilion, with an indurated base, that was not painful to palpation (Fig. 1).

There were no neck adenopathies and the intraoral examination was negative. No other lesions were observed in the area of the head and neck. He had a simultaneous interdigital lesion on the left foot with an ulcerous appearance that measured 0.5 cm (Fig. 2). It had a smooth surface, a serous exudate and there were numerous smaller sized macules on the sole of the same foot that were round and copper colored and painless to palpation (Fig. 3). Lastly, he had on his scrotum various small lesions (measuring less than 0.5 cm) that were ulcerated in appearance and painful on palpation (Fig. 4). The remaining physical examination was within normal limits.

A biopsy was carried out on the lip lesion that was inconclusive and laboratory tests were carried out for infection screening HBV (HbsAg: negative; Anti-HBc: positive; quantitative Anti-HBs: (>1000 mIU/ml), positive, HCV (ELISA-G: negative), HIV (Immunoblot: positive; ELISA IgG: positive; ELISA (second technique): positive; load (Chiron): 3.69 log copies of HIV-RNA/ml: lymphocyte count (CD+3): CD4: 43%, CD 8: 56%; CD 4/CD8 rate: 0.77, absolute CD4 count: 762 cells/ul, absolute CD8 count: 992 cells/ul), syphilis (PRP: Positive at 1:64. TPHA; Positive. Captia G ELISA: Positive (treponemal test)) and tuberculosis (Mantoux: negative). A complementary CSF study was not carried out given the absence of neurological symptoms and the short development period.

As the diagnosis was of syphilis in a patient that was carrying HIV, the treatment consisted in penicillin benzathine (2.4 mU) IM, there being complete resolution of the lesions after two weeks (Fig. 5 and 6). The serologic tests at 6 months confirmed the resolution of the symptoms.

Discussion

Syphilis or lues is a chronic systemic infection found worldwide that is transmitted through sexual contact. It is caused by a spirochete called Treponema pallidum (TP),^1,2 which is a slender spiral organism with a width of 0.25 mm and a length of 5 to 20 mm. It can be identified by its characteristic morphology and motility when observed by dark field microscopy or with fluorescence techniques. It does not grow in a laboratory medium, and it rarely reproduces itself in tissue cultures, nor will it survive for long outside the human body. It penetrates through mucosa and skin reaching the regional lymphatic nodes in a few hours, spreading through the organism rapidly.

Following the epidemics over the last few decades in conjunction with the so called «sexual revolution» (from the end on the 80s and during the 90s the incidence of primary and secondary syphilis doubled in black Americans due to cocaine abuse and prostitution). At the end of the nineties a decrease in the syphilis trend was observed due generally to a modification in sexual conduct as a result of the appearance of the HIV virus and to the intensive measures adopted by the public health services.³ However, lues is now reappearing posing a considerable problem for public health.4 Its incidence, like other sexually transmitted diseases (STD), has increased due, according to different epidemiological studies, to acquired immunodeficiency virus^5,6 with a prevalence described of up to 70% regarding this affection in patients carrying HIV.^4,7 Syphilis as a risk factor in the transmission of HIV has also been documented.^8,9 Finally, HIV virus infection can affect the natural course of the infection and its response to treatment.⁷

Bearing in mind the statistics that connect HIV with TP infection, ruling out HIV infection is recommended in all patients with syphilis (or any other STD) together with proper assessment of all HIV seropositive patients in order to rule out STD.

Syphilis left to develop freely has three clearly distinguishable stages. In the primary stage (primary syphilis) the clinical presentation consists in the appearance of a chancre, regional adenopathy and general symptoms of discomfort due to the dissemination of the Treponema from the inoculation area into the blood stream. In the secondary stage (secondary syphilis) a new constitutional set of symptoms appear. The nodes are affected generally and disseminated cutaneous sores known as syphilids appear. These can be of two types: macules (that appear earlier on) or papules that, being located on the palms or soles, are the most characteristic lesion during this period. Finally, in the tertiary stage the body is affected generally and any organ may be affected. During this period, among the symptoms that appear are the characteristic gummas and nervous system disorders.^1,2

Orally syphilis produces a chancre (red papule that quickly turns into a painful ulcer with a serum-sanguinolent scab), mucosal patches, gummas and associated adenopathies.

In patients with intercurrent HIV infection, these stages are not quite so clearly distinguishable as they overlap and the clinical presentation will be altered.^10-13 Thus for example, syphilis in patients infected with HIV present with secondary staging more frequently, and those with secondary syphilis are more likely to have chancres.^14,15 In a similar fashion, cases of neurosyphilis are being reported at earlier stages to those expected and with greater frequency, with this being one of the principal complications that appears when there is HIV-syphilis co-infection.^16-18 Within this framework it is also important for the clinician to be aware of the different possible systemic manifestations of lues and to be mindful, within these, of abnormal oral conditions¹⁹ as various diseases can affect patients with HIV that can lead to clinical symptoms at an oral level. In the case of syphilis, the oral cavity is the first extragenital location.^1,2

With regard to the case in this article, and in view of the lip lesion that led the patient to seek consultation with our service, the differential diagnosis was made, after ruling out the initial diagnosis of a lip ulcer due to herpes (as the infection was so florid), of either a lesion of a carcinoma type or what turned out to be, syphilis of the lip, that required nonsurgical treatment. We should emphasize that due to the initial diagnosis of a sexually transmitted disease, studies leading to the second diagnosis of HIV seropositivity were considered that permitted prior anti-retroviral treatment.

The usual diagnostic techniques for syphilis are divided into those that are direct, and based on the visualization of the spirochete under the microscope, and those that are indirect or serological techniques. These in turn are differentiated into non-treponemal (or reaginic) RPR (rapid plasma reagin) VDRL (venereal disease research laboratory), that are the most used, and which measure antibodies to the substances produced by damaged tissue, and treponemal tests such as FTAABS (fluorescent treponemal antibody absortion) and also TPHA (Treponema Pallidum hemaglutination assay) that assess the existence of antibodies to TP.^1,2,20 The application of different techniques has its indications as well as its limitations. Thus, P.E. is used in the direct examination of the exudates during the initial phases of the illness, although it can give false negatives if there are only a few spirochetes in the lesion; with the non-treponemal tests syphilis is not guaranteed when positive, although these are the best tests for evaluating treatment efficiency; and the treponemal tests are used for confirming positive results, however, they do not become negative even after the patient has been cured. Both types of serological tests tend to be carried out together using serum, plasma or CSF depending on the staging or on the suspicions as to how affected the patient is.^1,2

With regard to the diagnosis of syphilis in patients infected by HIV, this can be more complicated due to false serological reactions^21-26 and to the atypical presentation of lues when there is HIV infection.^10,14,15

The treatment required for syphilis depends of the stage of the disease. Penicillin is the drug of choice for all stages of syphilis. In order to cure syphilis, a plasma level of at least 0.03 UI/ml for 6 to 8 days is needed. During early staging, a single dose of 2.4 million units of Penicillin G Benzathine via intramuscular injections is sufficient (a satisfactory blood level for two weeks is produced). In late syphilis (cases that have been evolving for over a year) or of unknown duration, the same dose is recommended but repeated once a week for a period of three weeks. Finally, for the treatment of neurosyphilis, endovenous treatment should be included prior to these last doses.^1,2 In patients with allergies to penicillin, ceftriaxone can be used (1 gr IM every 3 days diluted in 3.6 ml of 1% lidocaine) or erythromycin or tetracycline (500 mg taken orally every six hours for two weeks) or doxycyline, but the effectiveness of these drugs is not well defined.

A greater failure rate in syphilis treatment has been observed in HIV positive patients,^13,27,28 however, the classical guidelines are considered useful for initial treatment. Lastly, clinical and serological checks every few months for a year, or for two if the disease is more advanced is essential. Also essential is the identification of any sexual contact the patient has had three months previously in early syphilis cases, and for a year in those cases that are more advanced.^1,2

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