Isolated Syphilitic Cervical Lymphadenopathy: Report of Two Cases and Review of the Literature

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.

Localised cervical lymphadenopathy: a rare presenting sign of syphilis

Recognising syphilis can be challenging due to enormous variability in disease presentation. We present a case of 56-year-old female patient, without any medical history, with unilateral cervical lymphadenopathy and night sweats since 3 weeks. Initial differential diagnosis consisted of infectious disease, lymphoproliferative disease and autoimmune disease. Despite considerable diagnostic efforts, including serological tests for common infectious diseases, a CAT scan and histologic examination, no diagnosis was found. After reconsideration, serologic testing for syphilis was performed and was positive. Hereby, the final diagnosis of syphilis was made. Neurosyphilis and HIV coinfection were ruled out before treatment with benzylpenicillin was initiated. After which our patient made a full recovery. Treatment delay could have been considerably diminished if the localised lymphadenopathy was recognised as possible syphilitic disease. In future cases this could not only prevent further dissemination and potential morbidity in the individual patient as well as further emergence within the population.

A case of primary syphilis characterised by lymphadenitis with abscess formation treated with only antibiotic without surgical excision of lymph node

Syphilis is an increasingly common infectious disease caused by the bacterium Treponema pallidum. Atypical clinical presentations occur that may delay its diagnosis and treatment. Regional enlargement of lymph nodes is seen in both primary and secondary stages. Such lymph nodes very rarely become abscesses. Antibiotics should be administered in this situation; however, if this fails, the lymph nodes should be surgically excised.

Secondary Syphilis with Pulmonary Involvement

A 39-year-old Japanese man presented to our hospital complaining of left chest pain and rash on the hands and feet. Plain thoracic computed tomography (CT) revealed multiple nodular shadows in the left lower lobe of the lung. A diagnosis of secondary syphilis was made based on the appearance of the rash and positive serologic tests for syphilis. The patient was started on amoxicillin but was switched to minocycline due to amoxicillin-induced rash on both forearms. Thoracic CT after five months of treatment revealed that the multiple lung nodular shadows had contracted, and secondary syphilis with pulmonary involvement was diagnosed.

Otorhinolaryngology manifestations secondary to oral sex

INTRODUCTION

Over the last few years, oral and pharyngeal signs and symptoms due to oral sex have increased significantly. However, no review articles related to this subject have been found in the medical literature. The objective of our study was to identify otorhinolaryngological manifestations associated with orogenital/oroanal contact, both in adults and children, in the context of consensual sex or sexual abuse.

METHODS

We performed a review of the medical literature on otorhinolaryngological pathology associated with oral sex published in the last 20 years in the PubMed database.

RESULTS

Otorhinolaryngological manifestations secondary to oral sex practice in adults can be infectious, tumoral or secondary to trauma. The more common signs and symptoms found in the literature were human papillomavirus infection (above all, condyloma acuminata and papilloma/condyloma), oral or pharyngeal syphilis, gonococcal pharyngitis, herpes simplex virus infection and pharyngitis from Chlamydia trachomatis. The incidence of human papillomavirus -induced oropharyngeal carcinoma has dramatically increased. In children past the neonatal period, the presence of condyloma acuminatus, syphilis, gonorrhoea or palatal ecchymosis (the last one, unless justified by other causes) should make us suspect sexual abuse.

CONCLUSIONS

Sexual habits have changed in the last decades, resulting in the appearance of otorhinolaryngological pathology that was rarely seen previously. For this reason, it is important for primary care physicians to have knowledge about the subject to perform correct diagnosis and posterior treatment. Some sexual abuse cases in children may also be suspected based on the knowledge of the characteristic oropharyngeal manifestations secondary to them.

Oropharyngeal Syphilis: Imaging and Pathologic Findings in Two Patients

Syphilis is a widespread infection with increasing frequency in developed countries, especially among men who have sex with men. We present two cases of oropharyngeal syphilis in two middle-aged men who presented with a painless tonsillar ulcer and progressive enlargement of cervical lymph nodes suspected of being a tonsillar tumour. A pathologic analysis of the ulcer led to an accurate diagnosis. We review the imaging and pathologic findings to emphasize the importance of taking syphilis into account in the differential diagnosis.

Diagnostic pitfalls in pathological diagnosis of infectious disease: patients with syphilitic lymphadenitis often present with inconspicuous history of infection

Retrospective study was applied to 16 cases of syphilitic lymphadenitis to elucidate the pathological diagnostic features. The typical morphology of syphilitic lymphadenitis includes: (i) well preserved or partially destroyed lymph node structure; (ii) reactive hyperplasia of lymph follicles with broadened germinal centers in the cortex and medulla of the lymph node; (iii) thickened fibrotic lymph node capsules with infiltration of plasma cells; and (iv) phlebitis and endarteritis in varying degree. Additional morphology includes: (i) focal histiocytes with ingested debris; (ii) noncaseating granuloma with epithelioid histiocytes and disperse giant cells; and (iii) hyperplastic centroblast and occasionally isolated mononuclear Reed-Sternberg cell-like giant cells. Treponema pallidum was identified in 15 of the 16 cases by immunohistochemical staining. The histopathological diagnosis of syphilitic lymphadenitis poses difficulty in differentiation from other infectious or neoplastic lymphadenopathies. The newly established Treponema pallidum antibody is sensitive to identification of Treponema pallidum in formalin fixed paraffin embedded tissue.

Cervical: Lymphadenopathy

The neck region contains around 300 lymph nodes (LNs) out of 800 LNs in the whole body. The detailed study of LNs by Rouviere in 1932 [1] and the later illustration of metastatic predilection of head and neck malignancies to certain LN regions by Lindberg et al. [2] paved the road to a clinically sound classification. The American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) and the American Joint Committee on Cancer (AJCC) developed the currently widely accepted levels classification of the cervical LNs (Table 8.1, Figs. 8.1 and 8.2).

Fluorescence in situ hybridization for the identification of Treponema pallidum in tissue sections

Syphilis is often called the great imitator because of its frequent atypical clinical manifestations that make the disease difficult to recognize. Because Treponema pallidum subsp. pallidum, the infectious agent of syphilis, is yet uncultivated in vitro, diagnosis is usually made using serology; however, in cases where serology is inconclusive or in patients with immunosuppression where these tests may be difficult to interpret, the availability of a molecular tool for direct diagnosis may be of pivotal importance. Here we present a fluorescence in situ hybridization (FISH) assay that simultaneously identifies and analyzes spatial distribution of T. pallidum in histological tissue sections. For this assay the species-specific FISH probe TPALL targeting the 16S rRNA of T. pallidum was designed in silico and evaluated using T. pallidum infected rabbit testicular tissue and a panel of non-syphilis spirochetes as positive and negative controls, respectively, before application to samples from four syphilis-patients. In a HIV positive patient, FISH showed the presence of T. pallidum in inguinal lymph node tissue. In a patient not suspected to suffer from syphilis but underwent surgery for phimosis, numerous T. pallidum cells were found in preputial tissue. In two cases with oral involvement, FISH was able to differentiate T. pallidum from oral treponemes and showed infection of the oral mucosa and tonsils, respectively. The TPALL FISH probe is now readily available for in situ identification of T. pallidum in selected clinical samples as well as T. pallidum research applications and animal models.