Syphilis: the renaissance of an old disease with oral implications

A retrospective analysis of syphilis cases with a focus on otolaryngology at a university hospital

OBJECTIVES

In recent years, there has been a notable increase in syphilis cases in Japan and Western countries. Syphilis, a classic sexually transmitted disease caused by treponemas, presents diagnostic challenges due to its diverse clinical manifestations. This study explores the diagnosis of syphilis in patients treated at our hospital.

METHODS

We retrospectively reviewed patients who visited our hospital between April 2015 and March 2024. The review focused on the patients' clinical backgrounds, onset times, symptoms, diagnostic processes, and clinical courses.

RESULTS

Our hospital had 45 cases of syphilis. Forty-five cases of syphilis were diagnosed as syphilis in our hospital (13 cases were diagnosed in the Otolaryngology: ENT department). The median age was 40 years, with a significant male predominance (male-to-female ratio of 34:11). The median duration from the onset of subjective symptoms to syphilis diagnosis was 54 days. The timeframe from the initial clinic visit to diagnosis ranged from 1 to 57 days, with a median of nine days. Notably, 47.5% of the patients reported a history of employment or patronage in the sex industry. 73.3% of patients presented to local clinics with any kind of subjective symptoms, but syphilis was often missed in the differential diagnosis. Patients visiting the ENT department were referred to our hospital with a diagnosis of persistent oral ulcer, oropharyngeal carcinoma and neck lymphadenopathy. Histological and cytological evaluation was performed in 33% of patients, but the diagnosis was often difficult to make. Additionally, some patients initially denied using sex services at their first visit but later disclosed this during subsequent visits to the Department of Infectious Diseases, highlighting the critical role of thorough medical history assessments.

CONCLUSION

Diagnosing syphilis can be challenging unless the physician specifically suspects it. It is crucial to consider syphilis in cases of pharyngeal mucosal inflammation and neck lymphadenopathy. This study highlights the need for heightened awareness and education regarding the signs and symptoms of syphilis, particularly oropharyngeal and skin findings, to ensure timely diagnosis and treatment.

Efficacy of Voluntary Medical Male Circumcision to Prevent HIV Infection Among Men Who Have Sex With Men : A Randomized Controlled Trial

BACKGROUND

Observational studies suggest that voluntary medical male circumcision (VMMC) may lower HIV risk among men who have sex with men (MSM). A randomized controlled trial (RCT) is needed to confirm this.

OBJECTIVE

To assess the efficacy of VMMC in preventing incident HIV infection among MSM.

DESIGN

An RCT with up to 12 months of follow-up. (Chinese Clinical Trial Registry: ChiCTR2000039436).

SETTING

8 cities in China.

PARTICIPANTS

Uncircumcised, HIV-seronegative men aged 18 to 49 years who self-reported predominantly practicing insertive anal intercourse and had 2 or more male sex partners in the past 6 months.

INTERVENTION

VMMC.

MEASUREMENTS

Rapid testing for HIV was done at baseline and at 3, 6, 9, and 12 months. Behavioral questionnaires and other tests for sexually transmitted infections were done at baseline, 6 months, and 12 months. The primary outcome was HIV seroconversion using an intention-to-treat analysis.

RESULTS

The study enrolled 124 men in the intervention group and 123 in the control group, who contributed 120.7 and 123.1 person-years of observation, respectively. There were 0 seroconversions in the intervention group (0 infections [95% CI, 0.0 to 3.1 infections] per 100 person-years) and 5 seroconversions in the control group (4.1 infections [CI, 1.3 to 9.5 infections] per 100 person-years). The HIV hazard ratio was 0.09 (CI, 0.00 to 0.81; P = 0.029), and the HIV incidence was lower in the intervention group (log-rank P = 0.025). The incidence rates of syphilis, herpes simplex virus type 2, and penile human papillomavirus were not statistically significantly different between the 2 groups. There was no evidence of HIV risk compensation.

LIMITATION

Few HIV seroconversions and limited follow-up period.

CONCLUSION

Among MSM who predominantly practice insertive anal intercourse, VMMC is efficacious in preventing incident HIV infection; MSM should be included in VMMC guidelines.

PRIMARY FUNDING SOURCE

The National Science and Technology Major Project of China.

Not Always a Malignant Tumour: A Quiz

Abstract missing (Quiz)

Oral Secondary Syphilis in an HIV-Positive Transgender Patient: A Case Report and Review of the Literature

BACKGROUND

Syphilis is a worldwide sexually transmitted infection caused by Treponema pallidum. In most cases, the oral manifestations of syphilis infection are associated with cutaneous involvement. However, the present case report is noteworthy since the oral lesions are the sole clinical sign in an HIV-positive transgender patient.

CASE PRESENTATIONS

We reported an uncommon case of secondary syphilis in a 37-year-old seropositive transgender male, whose diagnostic suspect was based only on oral mucosal lesions. The patient was referred to the Oral Medicine Unit for the presence of multiple undiagnosed painful oral lesions. The intraoral examination revealed the presence of white and red plaques on the right and the left buccal mucosa and several painful lesions localized on the upper and lower labial mucosa. No cutaneous lesions were observed. Considering the sexual history of the patient and clinical findings, secondary syphilis infection was suspected. The serologic analysis was conducted, and the diagnosis of syphilis was confirmed. Moreover, to exclude the presence of oral epithelial dysplasia or malignant disease, an incisional biopsy was performed.

DISCUSSION

Compared to the literature data, oral lesions as lone signs of secondary syphilis infection are uncommon, especially in HIV-positive patients. Syphilis and HIV coinfection create a concerning situation as they interact synergistically, leading to an increased risk of transmission and faster disease progression.

CONCLUSIONS

This case report emphasizes the importance of considering syphilis as a diagnostic possibility, even when oral lesions are the only clinical manifestations, especially in HIV-positive patients. Comprehensive evaluation, including a detailed sexual history and careful oral examination, is essential for accurate diagnosis and appropriate management in such cases.

Oral Manifestations in Monkeypox: A Scoping Review on Implications for Oral Health

BACKGROUND

The monkeypox outbreak in 2022 caused concern in the public. Infected patients usually present prodromal symptoms, such as lesions on their skin and mucous membranes, including the oral cavity. The current study aims to review the most common oral/perioral manifestations reported to date.

METHODS

A literature search was conducted in the PubMed, Research Gate, and Wiley Online Library databases, as well as in the Google search engine, using keywords related to the condition. Of the 56 publications identified, 30 were selected, including 27 case reports, two case series types, and one cross-sectional study published from 2003 to 2023 in endemic and non-endemic countries. Of the 54 patients in these studies, data on the oral symptoms and sites of monkeypox were interpreted from 47 patients.

RESULTS

Oral/perioral signs as one of the initial manifestations were reported in 23 out of 47 patients (48.93%). Out of the 47 patients with oral/perioral involvement, the most common signs/symptoms were sore throat, followed by ulcers, vesicles, dysphagia and odynophagia, and erythema.

CONCLUSION

The most common oral symptom of monkeypox is sore throat, followed by ulcers. The symptoms usually occur in the pharynx/oropharynx, followed by the tonsils and tongue. Adequate knowledge about the characteristics of this virus and their association with the oral cavity is necessary, and could help oral health professionals to distinguish between different infections.

Bacterial Lesions of the Oral Mucosa

Nonodontogenic bacterial infections of the oral cavity are not a common finding in the United States. Nevertheless, there has been an increase in prevalence of certain bacterial sexually transmitted diseases, such as syphilis and gonorrhea, and conditions such as tuberculosis still pose a serious threat to certain segments of the population. Finally, given the uncommon nature and pathophysiology of these diseases, diagnosis is often delayed, resulting in more clinically significant disease and potential contamination of individuals. Thus, it is prudent that clinicians be familiar with these uncommon but potentially serious infectious diseases, so treatment can be instituted promptly.

The Mucosal Manifestations of Syphilis in the Head and Neck

Objectives: Syphilis is a resurging disease which can present itself in many ways, including lesions within the head and neck mucosa. Some of these lesions may clinically mimic oral malignancies. This literature review aims to better characterize the mucosal presentations of syphilis. Methods: PubMed, EMBASE, and clinicaltrials.gov were searched for full-text, English articles published from 1950 to 2022 that reported patients with head and neck mucosal manifestations of syphilis. Articles were screened according to PRISMA guidelines. Results: One hundred forty-three manuscripts documenting 236 individual patients were included in the review. Patients with secondary syphilis accounted for 62% of patients presenting with head and neck mucosal lesions. The most common lesions found in primary and secondary syphilis were ulcerations, primarily found on the tongue, lips, and palate. While serologic studies are the gold standard for diagnosing syphilis, biopsy of these lesions have characteristic syphilitic changes. Conclusions: Syphilis' nickname of "The great imitator" remains to be true, and the head and neck mucosal manifestations of this disease can resemble commonly seen malignancies. Awareness of this disease and its lesions is prudent given the rising incidence of syphilis within the United States.

Exposing the Great Imitator: Proposal for a Holistic Diagnosis of Oral Secondary Syphilis in People Living with HIV

Oral secondary syphilis may mimic various infectious, neoplastic, or immune-mediated processes; hence, its diagnosis may represent a challenge. Early diagnosis of syphilis, a disease that has increased in recent decades, is essential for adequate management, particularly in people living with HIV (PLWH). This study aimed to comprehensively characterize oral secondary syphilis in a group of 47 PLWH. A group of PLWH with oral secondary syphilis attending four HIV-referral centers in Mexico City was included (2004-2021). Clinical and laboratory data were retrieved, and an exhaustive oral examination was performed following the established criteria. Demographic, clinicopathological, immunohistochemical, and serological features of the patients were analyzed. Approximately 11% of PLWH with oral secondary syphilis demonstrated negative Venereal Disease Research Laboratory tests. A noticeable feature was the absence of symptoms in 95.7% of cases, despite the clinically evident appearance of the lesions. In contrast to previous results, 18% of ulcerations were detected to be deep, crateriform, and infiltrative, and 22% of the mucous patches were highly keratotic lesions. Most samples (77.3%) showed superficial lymphoplasmacytic infiltrates in the superficial lamina propria, with perivascular and perineural patterns, and immunohistochemistry was positive in 66.7% of the cases. The "great imitator" appears not only clinically but also histopathologically and immunohistochemically, where features may be comparable with those of chronic inflammatory processes, deep infections, or malignant processes. Although not recommended as a routine assay, IHC could be a critical tool, particularly in PLWH with atypical clinical features or with negative and/or dubious serology.

Acquired oral syphilis: A multicenter study of 339 patients from South America

OBJECTIVE

To report the clinicopathologic features of acquired oral syphilis cases in South American countries.

MATERIALS AND METHODS

Clinical data were retrospectively collected from the records of 18 oral diagnostic services in Argentina, Brazil, Chile, Colombia, Venezuela, Uruguay, and Peru. Serologies of nontreponemal and treponemal tests were used for diagnosis.

RESULTS

The series comprised 339 cases of acquired oral syphilis. Secondary syphilis ranked as the most common stage (86.7%). Lesions were more frequent among males (58.0%) and young adults with a mean age of 33.3 years. Individuals aged 20-29 years were most affected (35.3%). The most commonly involved sites were the tongue (31.6%), lip/labial commissure (25.1%), and hard/soft palate (20.4%). Clinically, acquired oral syphilis usually presented as mucous patches (28.4%), papules (25.7%), and ulcers (18.1%). Skin manifestations occurred in 67.7% of individuals, while lymphadenopathy and fever were observed in 61.3% and 11.6% of all subjects, respectively. Most patients were treated with the benzathine penicillin G antibiotic.

CONCLUSION

This report validates the spread of acquired oral syphilis infection among young adults in South America. Our directives include accessible diagnostic tools for proper disease screening, surveillance, and counselling of affected individuals, especially in low- and middle-income countries.

[Syphilis infection in the ENT area]

The number of reported cases of syphilis has been increasing for years. The sexually transmitted disease is caused by the spirochete Treponema pallidum subspecies pallidum and progresses in different stages. Symptoms in the ENT area can occur in all stages. This means that a syphilis infection should always be considered by the ENT doctor as a differential diagnosis if the symptoms are suitable. Thus, with increasing oral sexual intercourse, the primary effect/hard chancre is more often observed in the oral cavity. In addition, symptoms can occur not only in the oral cavity, but also in the ear, nose, larynx, cervical and facial regions. The diagnosis is confirmed by direct pathogen detection or by serological detection. The spirochete cannot be cultivated. The therapeutic gold standard is the administration of benzathine penicillin G or procaine penicillin G. Doxycycline, macrolides or ceftriaxone are available as alternatives. In case of inner ear or cranial nerve involvement, the additional administration of a glucocorticoid is recommended. Before antibiotic therapy is administered, the patient must be informed about the possibility of a Jarisch-Herxheimer reaction. In cases of a syphilis infection, a collegial cooperation with the venereologists is always recommended so that an effective and comprehensive diagnosis and therapy can be carried out.

Syphilis D' Emblée: A case series of the great masquerader

Syphilis, a chronic infectious disease caused by Treponema pallidum subspecies pallidum, progresses through three arbitrary stages resulting in varied clinical manifestations. The aberrant presentation of syphilis in the secondary stage without any clinical evidence of the primary stage is referred to as syphilis d’ emblée. Here we report a series of six cases in male patients. Five out of six patients presented with multiple, non-pruritic, macular palmar, and/or plantar lesions. One patient had typical facial and perianal lesions of condyloma lata. The diagnosis was confirmed by a reactive VDRL with titers ranging from 1:16 to 1:64 and a positive Treponema pallidum hemagglutination assay (TPHA). Syphilis being a great imitator can present in different ways without a typical history of primary chancre following sexual exposure, and can mimic many dermatological disorders in its secondary stage. Unless physicians have a high index of suspicion, the diagnosis may be missed. Early identification aids in prompt initiation of therapy and prevention of disease progression to chronic stages and systemic manifestations.

Novel radiographic presentation of primary syphilis of the tonsil

A 61-year-old HIV+ male presented to an infectious disease clinic with a complaint of sore throat. A painless ulcerated mass was discovered on the right tonsil resulting in further evaluation with a CT scan of the neck. Imaging confirmed the presence of a mass centered on the palatine tonsil and associated lymphadenopathy. A presumptive diagnosis of HPV-related squamous cell carcinoma was made due to patient risk factors. However, multiple biopsies found no evidence of carcinoma, but instead revealed the presence of spirochetes that stained positive for T Pallidum. Soon after, the patient developed the characteristic copper-red maculopapular rash of secondary syphilis, indicating that the tonsillar mass was, in fact, a primary chancre. Since such chancres are most often found externally in the genital or anal region, they are seldom radiographically characterized, placing them low on the differential diagnosis for most radiologists. A high index of suspicion could aid future radiologists in placing primary syphilis higher on the differential diagnosis in similar cases in which the patient has appropriate risk factors, such as a known history of genital-oral sexually transmitted infections or an immunocompromised state. Prompt recognition of the nature of a primary syphilitic lesion can lead to rapid resolution of symptoms following treatment with intramuscular benzathine penicillin G, as eventually occurred in this case.

Assessing the drivers of syphilis among men who have sex with men in Switzerland reveals a key impact of screening frequency: A modelling study

Over the last decade, syphilis diagnoses among men-who-have-sex-with-men (MSM) have strongly increased in Europe. Understanding the drivers of the ongoing epidemic may aid to curb transmissions. In order to identify the drivers of syphilis transmission in MSM in Switzerland between 2006 and 2017 as well as the effect of potential interventions, we set up an epidemiological model stratified by syphilis stage, HIV-diagnosis, and behavioral factors to account for syphilis infectiousness and risk for transmission. In the main model, we used ‘reported non-steady partners’ (nsP) as the main proxy for sexual risk. We parameterized the model using data from the Swiss HIV Cohort Study, Swiss Voluntary Counselling and Testing center, cross-sectional surveys among the Swiss MSM population, and published syphilis notifications from the Federal Office of Public Health. The main model reproduced the increase in syphilis diagnoses from 168 cases in 2006 to 418 cases in 2017. It estimated that between 2006 and 2017, MSM with HIV diagnosis had 45.9 times the median syphilis incidence of MSM without HIV diagnosis. Defining risk as condomless anal intercourse with nsP decreased model accuracy (sum of squared weighted residuals, 378.8 vs. 148.3). Counterfactual scenarios suggested that increasing screening of MSM without HIV diagnosis and with nsP from once every two years to twice per year may reduce syphilis incidence (at most 12.8% reduction by 2017). Whereas, increasing screening among MSM with HIV diagnosis and with nsP from once per year to twice per year may substantially reduce syphilis incidence over time (at least 63.5% reduction by 2017). The model suggests that reporting nsP regardless of condom use is suitable for risk stratification when modelling syphilis transmission. More frequent screening of MSM with HIV diagnosis, particularly those with nsP may aid to curb syphilis transmission.

Syphilis, one of the most common sexually transmitted infections, remains a major public health problem. Over the last decade, a rising number of diagnoses especially in men-who-have-sex-with-men (MSM) was observed in Western Europe and Northern America. In Switzerland, the number of syphilis diagnoses in MSM tripled between 2006 and 2017. In this study, we used a mathematical model to assess the drivers of this increase among MSM in Switzerland. Our model could reproduce the increase in syphilis diagnoses in both MSM with and without HIV diagnosis between 2006 and 2017. Based on this model we found that MSM with HIV diagnosis have an over 45 times higher syphilis incidence than MSM without HIV diagnosis. Furthermore, we found that reported sex with non-steady partners is a useful proxy of behavioral risk. Considering counterfactual scenarios, we showed that increasing the screening frequency for syphilis among MSM with HIV diagnosis and with non-steady partners from once a year to twice per year can reduce syphilis incidence by 63.5% to 99.2%.

Unexpected Reason for Non-healing Oral Ulcers: Syphilis

Syphilis is a sexually transmitted infectious disease caused by Treponema pallidum and characterized by a complex and variable clinical presentation. Cases of unexpected oral syphilis presenting as non-healing ulcers are uncommonly reported. We report 3 cases (one female and two males, aged 35, 35, and 56 years, respectively) in which patients presented with non-healing oral ulcers. Biopsies revealed surface ulceration and a significant neutrophilic infiltrate rather than the more conventional plasma cell infiltrate seen with most reported syphilis infections, potentially leading to an inaccurate diagnosis. Treponema pallidum immunohistochemistry highlighted spirochetes within the epithelium, with additional diagnostic confirmation by serum T. pallidum particle agglutination assay. Sexual history documentation by the clinician with nonspecific oral ulcers is paramount to aiding diagnosis and leading to proper management. Further, it is important to perform immunohistochemistry for T. pallidum in oral biopsies from non-healing ulcers, especially when clinical history raises the differential diagnosis or when other clinical manifestations may support this consideration.

Oral manifestations of syphilis: an epidemiological study in southern Brazil

BACKGROUND

Syphilis is an infectious, sexually transmitted disease with varied oral manifestations, that can mimic other lesions. This study aimed to conduct an epidemiological survey of cases of syphilis, diagnosed from oral manifestations, establishing the sociodemographic profile of patients and clinical characteristics of oral lesions.

METHODS

The medical records of patients with oral lesions of syphilis acquired were reviewed, and 109 cases were selected.

RESULTS

The mean age of the patients was 34.4 years and, of these, 51% were male. In 105 cases, the disease was diagnosed in the secondary stage; in three cases, in the primary stage; and, in one case, in the tertiary stage. The cases of primary syphilis presented as single and ulcerated nodules, and the case of tertiary syphilis, as a necrotic lesion in the palate. In 86% of cases of secondary syphilis, there were multicentric lesions, presenting as grayish-white plaques (85%), associated or not with erosive and/or ulcerated lesions (33%), mostly affecting the labial mucosa and tongue. In 91.7% of cases painful symptoms were reported.

CONCLUSION

Considering the increase in syphilis, it is extremely important that dentists recognize its oral manifestations, because early diagnosis and treatment can minimize the risks of complications and transmission.

Oral Manifestations of Syphilis: a Review of the Clinical and Histopathologic Characteristics of a Reemerging Entity with Report of 19 New Cases

BACKGROUND

Syphilis is a sexually-transmitted infectious disease caused by Treponema pallidum. Cases of primary and secondary syphilis are on the rise in the United States, with a 14.4% increase in new cases noted from 2017 to 2018 and an escalation of 71% between the years 2014 and 2018. Fulfilling its nickname of "the great imitator," oral manifestations of syphilis may mimic a variety of infectious, neoplastic, or immune-mediated processes, both clinically and histopathologically. This large spectrum of appearances can create a diagnostic challenge to the clinician and/or pathologist, leading to delay in diagnosis or misdiagnosis.

METHODS

A database of oral syphilis cases was created from archives at the University of Kentucky, University of Pittsburgh, LIJMC, Columbia University MC, and University of Tennessee. The age, sex, race, location, duration, and clinical description were recorded. Cases without positive reaction upon immunohistochemistry or serologic tests were excluded.

RESULTS

We identified 19 new cases of oral syphilis (17 males, one female, and one case unknown sex) and described the clinical and histopathological features of this re-emerging and potentially fatal disease. All cases demonstrated dense lymphoplasmacytic inflammation, often with inflammatory exocytosis or ulceration at the surface, and perivascular inflammation.

CONCLUSIONS

Early recognition of the histopathologic and clinical manifestations of oral syphilis is imperative for prompt diagnosis, improved patient outcomes, and disease prevention.

Sonographic appearance of syphilitic induration mimicking squamous cell carcinoma in the lower lip: a case report

Background

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. Recently, its incidence has been increasing worldwide. We encountered a young woman who presented with induration mimicking squamous cell carcinoma in the lower lip, without major medical conditions.

Case presentation

A 25-year-old Japanese woman presented with a 1-month history of a painless induration in her lower lip. Because squamous cell carcinoma was suspected, a preoperation work up was performed, including laboratory tests, an ultrasonographic examination, and a biopsy. The ultrasonography findings showed an oval-shaped 17 × 11 × 12 mm tumor-like lesion with heterogeneous internal echo and an indistinct border. A pressure test and color Doppler sonography revealed that the lesion was soft with a very abundant blood flow. These findings suggested the possibility of underlying inflammatory causes rather than a neoplastic tumor. Serology tests for syphilis, including the anti-Treponema pallidum antibody and reactive rapid plasma reagin tests, were positive. The biopsy revealed no malignancy. Finally, she was diagnosed as having primary syphilis and treated with amoxicillin for 28 days. The rapid plasma reagin value gradually decreased and the initial induration in her lower lip disappeared.

Conclusion

This case highlights the need for prompt examinations for possible underlying infective causes, such as syphilis, when seeing a painless induration with ulcer in the lip. Ultrasonography was helpful in the differential diagnosis of a tumor-like lesion and should be included in addition to syphilis serology tests, such as anti-Treponema pallidum antibody and rapid plasma reagin tests.

A nonspecific ulcer on upper lip presented as the first and sole sign of syphilis

Syphilis, a sexually transmitted disease, can be categorized as acquired syphilis and congenital syphilis, manifesting diverse lesions involving multiple sites. Oral manifestations at the primary stage of acquired syphilis are usually characterized by its short period and non-specific varied presentations. And oral ulcers as initial and the only presentation of syphilis oral lesions are infrequent and occur in less than 2% of patients. Because of its transient nature and variable manifestations which could mimic other oral ulcerative lesions, oral syphilis presenting as sole ulceration at early stage can be easily neglected and rather difficult to diagnose. Herein, we report a 35-year-old female patient manifested a sole atypical ulceration on her upper lip for approximately 1 month. We highlighted the importance of early and accurate diagnosis, focused on the characteristics of oral chancre, and gave an insight to the differential diagnoses, which would be enlightening and useful in clinical practice.

Circumcision to prevent HIV and other sexually transmitted infections in men who have sex with men: a systematic review and meta-analysis of global data

BACKGROUND

Men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmitted infections (STIs) worldwide. Previous reviews investigating the role of circumcision in preventing HIV and other STIs among MSM were inconclusive. Many new studies have emerged in the past decade. To inform global prevention strategies for HIV and other STIs among MSM, we reviewed all available evidence on the associations between circumcision and HIV and other STIs among MSM.

METHODS

In this systematic review and meta-analysis, we searched PubMed, Web of Science, BioMed Central, Scopus, ResearchGate, Cochrane Library, Embase, PsycINFO, Google Scholar, and websites of international HIV and STI conferences for studies published before March 8, 2018. Interventional or observational studies containing original quantitative data describing associations between circumcision and incident or prevalent infection of HIV and other STIs among MSM were included. Studies were excluded if MSM could not be distinguished from men who have sex with women only. We calculated pooled odds ratios (ORs) and their 95% CIs using random-effect models. We assessed risk of bias using the Newcastle-Ottawa scale.

FINDINGS

We identified 62 observational studies including 119 248 MSM. Circumcision was associated with 23% reduced odds of HIV infection among MSM overall (OR 0·77, 95% CI 0·67-0·89; number of estimates [k]=45; heterogeneity I²=77%). Circumcision was protective against HIV infection among MSM in countries of low and middle income (0·58, 0·41-0·83; k=23; I²=77%) but not among MSM in high-income countries (0·99, 0·90-1·09; k=20; I²=40%). Circumcision was associated with reduced odds of herpes simplex virus (HSV) infection among MSM overall (0·84, 0·75-0·95; k=5; I²=0%) and penile human papillomavirus (HPV) infection among HIV-infected MSM (0·71, 0·51-0·99; k=3; I²=0%).

INTERPRETATION

We found evidence that circumcision is likely to protect MSM from HIV infection, particularly in countries of low and middle income. Circumcision might also protect MSM from HSV and penile HPV infection. MSM should be included in campaigns promoting circumcision among men in countries of low and middle income. In view of the substantial proportion of MSM in countries of low and middle income who also have sex with women, well designed longitudinal studies differentiating MSM only and bisexual men are needed to clarify the effect of circumcision on male-to-male transmission of HIV and other STIs.

FUNDING

National Natural Science Foundation of China, National Science and Technology Major Project of China, Australian National Health and Medical Research Council Early Career Fellowship, Sanming Project of Medicine in Shenzhen, National Institutes of Health, Mega Projects of National Science Research for the 13th Five-Year Plan, Doris Duke Charitable Foundation.

Beyond appearance: An unusual manifestation of isolated oral secondary syphilis

Syphilis is a sexually acquired chronic infection caused by Treponema pallidum and is characterized by a variety of clinical manifestations. The secondary stage of the disease results from the hematogenous and lymphatic dissemination of treponemes after a few weeks or months, and it is characterized by recurrent activity of the disease, with muco-cutaneous as well as systemic manifestations. Mucosal lesions range from small, superficial ulcers that resemble painless aphthae to large gray plaques, and they are generally associated with systemic manifestations of the disease. The exclusive asymptomatic oral localization not associated with general manifestations is uncommon but may actually be unrecognized and under-reported. We report a case of isolated oral manifestation as the unique presentation of secondary syphilis.

Oral epithelial dysplasia: Causes, quantification, prognosis, and management challenges

Oral epithelial dysplasia is a spectrum of architectural and cytological epithelial changes caused by accumulation of genetic changes, and is associated with an increased risk of progression to squamous cell carcinoma. It is a microscopic diagnosis of immense clinical importance. The initial reports of oral potentially malignant disorders with oral epithelial dysplasia transforming to oral cancer helped in understanding the nature of oral malignancies. Since then, clinical studies on oral potentially malignant disorders have combined microscopic findings of oral epithelial dysplasia to assess the malignant transformation potential of different grades of epithelial dysplasia. A significant amount of scientific literature has amassed on oral epithelial dysplasia relating to aspects of its diagnosis and management. However, the evidence base is weak as a result of the significant variability of published research. Poorly described study methods, variability in different oral epithelial dysplasia grading systems, inter- and intra-examiner variability causing issues of reliability, inadequate sample size, and inconsistent durations of follow-up are some of the methodological issues contributing to the failure to provide dependable information. Randomized clinical trials on the malignant transformation potential of oral epithelial dysplasia and its treatment outcomes are limited. This comprehensive literature review on oral epithelial dysplasia summarizes the scientific knowledge published in the scientific literature in English since its first description. The historical development, etiological factors, grading systems, diagnostic criteria, assessment of risk factors and prevention of malignant transformation, management principles of different grades of oral epithelial dysplasia (surgical and nonsurgical), recommendations on follow-up, and prognostic indicators are discussed in detail.

Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management

For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.

Head and neck involvement with histoplasmosis; the great masquerader

INTRODUCTION

Head and neck involvement with histoplasmosis usually occurs as a part of the disseminated illness. There are no pathognomic features of the upper aerodigestive tract involvement and the lesion may mimic a host of other conditions. The current report presents our experience with head and neck histoplasmosis in a non-endemic tertiary care center.

MATERIALS AND METHODS

We present a case of disseminated histoplasmosis with oral symptoms and lesions as the chief complaints. A 10 years' retrospective institutional database search was undertaken to identify the patients with histoplasmosis affecting head and neck region treated at our institution. The demographic and treatment details of the patients were reviewed.

RESULTS

In addition to the index patient, four more patients (two with gingivobuccal and one each with nasal and laryngeal histoplasmosis) were found. Out of the five patients, only one patient was found to have underlying immunosuppression. All of the patients were diagnosed with biopsy showing typical appearance of the intracellular organism. All the patients were satisfactorily treated with systemic antifungal treatment.

CONCLUSION

Upper aerodigestive tract involvement with histoplasmosis can present as an intriguing clinical puzzle. A high index of suspicion is needed and biopsy is the gold standard for the diagnosis. Intravenous Liposomal Amphotericin B and oral Itraconazole are standard treatment agents of choice and are highly efficacious in achieving cure.

The oral manifestations of syphilitic disease: a case report

Background

Syphilis is a sexually transmitted bacterial infection of the spirochete, Treponema pallidum. While primary syphilis often involves genitalia, oral manifestations are observed in a subset of patients. These lesions are often associated with submandibular and cervical lymphadenopathy. This is a case report of a primary syphilitic lesion located on the hard palate of the oral cavity, with only a very few cases described previously.

Case presentation

We describe a rare case of syphilis in a 59-year-old African American man presenting with subjective fevers, chills, marked submental lymphadenopathy, a diffuse skin rash, and an ulcer of the hard palate.

Conclusions

This case report demonstrates the importance of maintaining a high index of suspicion for syphilitic infection when a patient presents with nonspecific symptoms, a diffuse rash, and an oral lesion.

Syphilis of the oropharynx: Case series of "The Great Masquerader"

OBJECTIVE

Syphilis is a sexually transmitted infection with various presentations. Although, oropharyngeal manifestations are known to occur, the purpose of this study is to present the first case series in which the lesions were initially mistaken for human-papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC).

METHODS

A multi-institutional retrospective review.

RESULTS

Six cases of oropharyngeal syphilis were initially thought to be secondary to OPSCC due to presentation. Symptoms were vague and exam findings consisted of either a tonsillar or base of tongue mass, or lymphadenopathy. Biopsies were negative for OPSCC. Further workup diagnosed syphilis, with resolution of symptoms and lesions after antibiotic treatment.

CONCLUSIONS

Head and neck manifestations of syphilis have been reported in the literature. However, this is the first series reporting on oropharyngeal syphilis masquerading as HPV-related OPSCC. Ultimately, otolaryngologists must maintain a high suspicion for syphilis in order to ensure prompt diagnosis and treatment.

Diagnosing acquired syphilis through oral lesions: the 12 year experience of an Oral Medicine Center

INTRODUCTION

A resurgence of syphilis in Brazil has been reported in recent years.

OBJECTIVE

With this in mind, the present study sought to investigate the frequency, demographics, and clinical characteristics of patients with acquired syphilis with oral involvement who received medical care at an Oral Medicine Reference Center in a Brazilian Public Hospital.

METHODS

A retrospective study, spanning a period of 12 years, was performed to identify changing trends in syphilis over time. Medical records from all patients diagnosed with acquired syphilis who received medical care at the Hospital's Oral Medicine Clinic from 2005 to 2016 were reviewed, and the demographic and clinical data were collected.

RESULTS

A total of 85 patients had been diagnosed with acquired syphilis, with a significant increase in the number of cases over the past 5 years. Patients ranged from 16 to 76 years of age, with a peak in the third and fourth decades. Forty-eight cases affected males (56.5%), while 37 cases affected females (43.5%). Most of the oral lesions appeared as unique ulcers or plaques, with the lips and tongue representing the most affected sites. All cases were positive for Venereal Disease Research Laboratory or Fluorescent Treponemal Antibody Absorption, and treatment was performed with Penicillin G benzathine in most cases (84.7%).

CONCLUSION

The frequency of oral syphilis has been rising over time and oral lesions may well represent a diagnostic clue; therefore, oral health professionals must be made aware and properly trained in an attempt to develop a high degree of clinical suspicion in the diagnosis of syphilis.

An Unusual Case of Tertiary Syphilis Behaving Like Tongue Squamous Cell Carcinoma

Syphilis may present with a myriad of oral manifestations in the primary, secondary, and tertiary stages, and may be confused with malignancy. Despite a rise in the incidence of syphilis, tertiary syphilis is exceedingly rare. Tertiary syphilis gummas usually affect the hard palate, while tongue involvement is very rare. A 55-year-old male with extensive smoking and alcohol use was referred for malignancy evaluation with an ulcerative mass creating a tongue cleft, and a positron emission tomography scan suggestive for malignancy. Biopsy results demonstrated no carcinoma but histology demonstrated granulomatous inflammation. Further laboratory results demonstrated elevated rapid plasma reagin titers with Treponema pallidum immunoglobulin G antibodies present. The patient was diagnosed with tertiary syphilis, received appropriate antibiotic therapy, and had healing of the tongue with a persistent cleft. Syphilis may mimic many disease processes. As such, it is important to include this disease in the differential of an unusual tongue lesion. An oral lesion may be the first sign of infection.

Forty cases of acquired oral syphilis and a review of the literature

The aim of this study was to describe 40 cases of acquired oral syphilis (AOS) and to discuss the distribution of demographic characteristics, clinical features, and differential diagnosis of the disease. A retrospective study was conducted covering a 17-year period at a single institution in southern Brazil. Moreover, a literature review was performed through a search of the PubMed database for articles on AOS published between 1955 and March 2018. Data were analyzed descriptively. The predominant group within the case series was male patients in their twenties. The vast majority of cases (92.5%) were in the secondary stage of the disease. The lips were the most commonly affected site, with greyish-white mucous patches and reddish ulcers. In the literature review, the largest number of reported cases came from North America. Male patients in the third and fourth decades of life were most affected. AOS occurred more commonly as mucous patches and ulcers on the tongue and palate. Similarities regarding the distribution by sex, age, and anatomical location were found in the present study when compared to cases reported elsewhere. Clinicians, oral pathologists, and maxillofacial surgeons should familiarize themselves with the variable spectrum of signs and symptoms of AOS in their clinical practice to improve diagnosis and management.

Blood-borne and sexually transmitted infections: a cross-sectional study in a Swiss prison

Background

Incarcerated people carry a high burden of infection, including blood-borne diseases (BBDs). It is also known that one million people contract a sexually transmitted infection (STI) every day worldwide, which represents a global public health challenge. However, data regarding the prevalence of STIs and the risk factors among incarcerated populations are lacking. The objective of this study was to determine the prevalence and associated factors of BBDs and STIs among detainees in the largest pre-trial prison in Switzerland.

Methods

In a cross-sectional study conducted at the Champ-Dollon pre-trial prison, 273 male detainees answered a standardized questionnaire and were screened for syphilis, herpes simplex virus 2 (HSV-2), HIV, and hepatitis C (HCV). Prevalence rates and associations of BBDs and STIs with risk factors were computed.

Results

Most participants (90.9%) were migrants from outside Western Europe, and 5.9% were injecting drug users. HCV was diagnosed among 6.2% of participants (antibody prevalence). The prevalence of HCV was higher among injecting drug users (81.2%) than non-injectors (1.6%). The prevalence of HIV, syphilis, and HSV-2 was 0.4%, 1.1%, and 22.4%, respectively. HCV was associated with a history of injecting drug use and HSV-2 with a lower education level and being older than 26 years.

Conclusions

This study showed the infection prevalence of 2–9 times higher among detainees than in the Swiss community. It also illustrated that these infections are associated with sociodemographic and risk factors. Therefore, the prison environment offers an opportunity to strengthen infectious disease control programs targeting specific subgroups of at-risk people. Such programs would benefit both the prison population and broader society.

Oral ulcers as a presentation of secondary syphilis

The incidence of syphilis is increasing, and it typically presents in patients with known risk factors, often to genitourinary physicians. Patients presenting to a dermatologist or ophthalmologist will more likely have secondary syphilis, with the potential for having the associated complications. Early recognition is therefore vital to limit both the disease and risk of further contact spread. In this review, we include two case histories demonstrating the value of recognizing oral signs. Additionally, we review the currently accepted diagnostic and therapeutic recommendations.

Oral findings in secondary syphilis

Background

Syphilis is a sexually transmitted disease caused by Treponema pallidum. However, there are of hematogenic and vertical transmission. All health care professionals must be aware of the manifestations of this condition, such as oral lesions.

Objectives

This study to analyze and compare four clinical cases of syphilis that were diagnosed based on lesions in the oral cavity with published literature.

Material and Methods

Four patients with a confirmed sorologic and clinical diagnosis of syphilis were examined, confirmated from manifestation of oral lesions together with analysis of serological laboratory tests and histopathological analyses.

Results

Lesions were found in classic sites such as lips, tongue and skin. However, there were also lesions on the hard palate, and labial commissure, which correspond to less than 5% of the syphilis oral manifestations.

Conclusions

The practice of unprotected oral sex may result in infection and development of syphilis. The acknowledgment of the oral manifestations of syphilis in all its period of training for health professionals is of basic importance, the association of clinical features, histopathological findings and serological tests are required to complete the diagnosis and correct treatment.

Key words:Oral syphilis, treponema infections, secondary syphilis.

Nasoseptal Perforation: from Etiology to Treatment

PURPOSE OF REVIEW

Nasal septum perforation (NSP) is a communication between the two nasal cavities. This review contributes to the better knowledge of NSP causes, diagnosis, and treatment.

RECENT FINDINGS

NSP prevalence is about 1%. Clinical presentation may range from absence of symptoms to the presence of bothersome sinonasal symptoms. NSP is more frequently caused by trauma or post-surgery, inflammatory diseases, and abuse substances. Conservative management (nasal irrigation, topical use of antibiotic or lubricant ointments, or placement of prosthesis) is considered the first-line treatment. Symptomatic NSP not improving with local therapies usually requires surgical approach. Selection of the technique for the endoscopic septal repair depends on perforation characteristics and surgeon experience. When NSP is diagnosed, its cause has to be promptly determined. Most of them can be controlled with conservative measures. Surgical/endoscopic approaches are usually needed in refractory cases, and new repair techniques have to be considered.

The association between human perceived heat and early-stage syphilis and its variance: Results from a case-report system

BACKGROUND

The relationship between temperature and syphilis is poorly understood despite clues and suggestions from previous studies. We examined the association between human perceived temperature (humidex) and the relative risk of early-stage syphilis in the most affected area of China, as well as its variance across social-economic status and age groups.

METHODS

Information regarding early-stage (primary and secondary) syphilis cases reported to the China Case Report System between 2005-2013 from Guangdong province was analyzed in this study. Weather data were obtained from the National Meteorological Information Center. Distributed lag nonlinear models were applied to assess the relationship between humidex and the relative risk of early-stage syphilis. Results were further stratified by social-economic status and age groups.

RESULTS

The relative risks of early-stage syphilis mainly increased with increased humidex, and were elevated when the humidex was around 30 or greater than 38. The humidex-RR association for the 15-40 age group was similar to the scenario pooled across the age groups, particularly in the Pearl-River Delta Region. The relative risk of syphilis in the elderly for the non-Pearl-River Delta Region did not show a clear change with humidex, whereas that in the Pearl-River Delta Region substantially increased, particularly when humidex was above 25.

CONCLUSIONS

Human perceived temperature was positively related to the relative risk of early-stage syphilis. People in the Pearl-River Delta Region tended to be more sensitive, with relative risk elevated at potential comfortable times or under excessively hot conditions. The vulnerability of the elderly in the Pearl-River Delta Region is concerning.

A non-healing syphilid: Another face of the great imitator

The global re-emergence of syphilis is an exigent public health issue requiring both clinicians and public health practitioners to become familiar with the myriad manifestations of this great imitator. This report describes a case of an originally undiagnosed chronic oral syphilitic chancre, subsequently confirmed by both PCR and immunohistochemistry.

Autoimmune Disease Manifestations in the Oral Cavity

Immune-related disorders of the oral cavity may occur as primary disease process, secondary to systemic disease or neoplasm, or as a reaction to medications and other agents. The entities represented within this group may vary significantly by severity, clinical presentation, microscopic presentation, and special testing results. The selected immune-related conditions of the oral cavity in this article are categorized and presented by their prototypical tissue reaction patterns: vesiculobullous, including acantholytic and subepithelial separation; psoriasiform; spongiotic; and lichenoid reaction patterns.

Oral Syphilis: A Reemerging Infection Prompting Clinicians' Alertness

Syphilis is a rare but increasing disease. Due to changing sexual habits, presentation of oral manifestations may rise. Since syphilis may mimic other oral manifestations, diagnoses can be difficult. Clinicians need to be aware that ambiguous oral manifestations may in fact be caused by oral syphilis. Here, we present a case of extended diagnostic delay highlighting the importance of consulting an expert in infectious diseases in case of obscure oral lesions not responding to standard treatment. Despite seven visits to six different medical doctors, a patient who presented with oral syphilis was continuously misdiagnosed. After 6 months of increasing complaints and deteriorating severity of disease, the patient was referred to an oral and maxillofacial surgeon where the correct diagnosis was determined and proper treatment initiated.

Secondary syphilis in the oral cavity and the role of the dental surgeon in STD prevention, diagnosis and treatment: a case series study

Syphilis is an infectious disease caused by the bacterium Treponema pallidum. Syphilis has three clinical stages and may present various oral manifestations, mainly at the secondary stage. The disease mimics other more common oral mucosa lesions, going undiagnosed and with no proper treatment. Despite the advancements in medicine toward prevention, diagnosis, and treatment syphilis remains a public health problem worldwide. In this sense, dental surgeons should be able to identify the most common manifestations of the disease in the oral cavity, pointing to the role of this professional in prevention and diagnosis. This study describes a case series of seven patients with secondary syphilis presenting different oral manifestations.