Case report
Syphilis gastritis: a case report Kuan Lai1, Nicolas Pinto-Sander2, Daniel Richardson2, Shanshan Wei1 and Kang Zeng1
International Journal of STD & AIDS 2018, Vol. 29(7) 723–725 ! The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462417711623 journals.sagepub.com/home/std
Abstract Awareness of the spectrum of clinical manifestations of syphilis, especially uncommon changes, is essential for diagnosis and effective management of patients. A 48-year-old Han businessman presented to the ear, nose and throat surgeons with an eight-week history of epigastric pain, a four-week history of a widespread non-itchy rash including the scrotal skin and a one-week history of tinnitus and dizziness. On examination, he was afebrile with widespread lymphadenopathy and a maculopapular rash affecting his trunk and scrotum. His abdomen was soft but tender in the epigastrium. The Treponema pallidum particle agglutination assay result was positive, and the rapid plasma reagin was 1:2. Gastroscopy showed ulcers in the gastric antrum and pylorus. Histopathological examination of gastric mucosa lesions showed a large amount of lymphoplasmacytic infiltrate detected in the lamina propria of the gastric mucosa. The T. pallidum Liferiver real time polymerase chain reaction kit assay performed on specimens from skin lesions and gastric mucosal tissue were positive. The patient was treated with intravenous sodium penicillin followed by intramuscular benzathine penicillin. On the fourth day of the treatment, the rash, epigastric pain and lymphadenopathy subsided. Two weeks after treatment, the tinnitus alleviated and vertigo disappeared.
Keywords Syphilis, gastritis, epigastric pain Date received: 6 February 2017; accepted: 1 May 2017
Case presentation History A 48-year-old Han businessman presented to the ear, nose and throat (ENT) surgeons with an eight-week history of epigastric pain, a four-week history of a widespread non-itchy rash including the scrotal skin and a one-week history of tinnitus and dizziness. On further questioning, he admitted that six months previously he developed multiple non-tender ulcers on the right coronal rim of his penis which lasted eight weeks and spontaneously resolved. The patient revealed multiple episodes of condomless vaginal sex with three regular female partners in the last six months.
Examination On examination, he was afebrile with widespread lymphadenopathy and a maculopapular rash affecting his trunk and scrotum, but not the acral surfaces. His abdomen was soft but tender in the epigastrium with no rebound tenderness.
Investigations The white blood cell count, ALT, AST, creatinine and amylase were all in normal range. The HIV combi PT 4th generation test was negative. The Treponema pallidum particle agglutination (TPPA) assay result was positive, and the rapid plasma reagin (RPR) was 1:2. MRI of the brain was normal. The audiometry result showed binaural mild sensorineural hearing loss and gastroscopy (Figure 1(a)) showed ulcers in the gastric antrum and pylorus. Positron emission tomography–computed tomography (PET-CT) revealed multiple reactive enlarged lymph nodes above and below the diaphragm. 1 Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China 2 Claude Nicol Centre, Royal Sussex County Hospital, Brighton, UK
Corresponding author: Kang Zeng, Department of Dermatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, the People’s Republic of China. Email:
[email protected]
724
International Journal of STD & AIDS 29(7) examination, the gastric ulcers had mainly healed, with only a few small residual ulcers in the pylorus. The histopathological examination showed a significant decrease in the amount of lymphoplasmacytic infiltrate. The T. pallidum DNA test of gastric mucosa lesions was negative. Three months after treatment, the audiometry test indicated only mild sensorineural deafness in the left ear. The RPR, although initially measured 1:8 in the first two weeks after commencing treatment, was now down to 1:2 again.
Discussion
Figure 1. Gastroscopy: (a) before the treatment; (b) after the treatment.
Histopathological examination of gastric mucosa lesions showed a large amount of lymphoplasmacytic infiltrate detected in the lamina propria of the gastric mucosa. Histopathological examination of the abdominal wall and scrotum skin lesion biopsies conformed to changes observed in syphilis. The T. pallidum Liferiver real time polymerase chain reaction (PCR) assay results of skin lesions and gastric mucosal tissue were positive. The cerebrospinal fluid examination revealed normal white blood cell count, protein, TPPA and venereal disease research laboratory (VDRL) test.
Treatment The patient was treated with sodium penicillin (4,000,000 U IV q 4 h 14 d), followed by weekly benzathine penicillin (2,400,000 U IM) for three weeks. On the fourth day of the treatment, the rash, epigastric pain and lymphadenopathy subsided.
Follow-up Two weeks after treatment, the tinnitus alleviated and vertigo disappeared. The patient underwent repeat gastroscopy (Figure 1(b)). Compared with the previous
The patient described was admitted for investigation for tinnitus, dizziness, epigastric pain, lymphadenopathy and rash. After comprehensive investigations, he was diagnosed with secondary syphilis with gastric and sensorineural involvement. Syphilis is sexually transmitted and caused by the bacterium T. pallidum. The incidence of syphilis is increasing globally1 and clinicians need to be aware of the clinical manifestations. The organism spreads from the primary lesion haematogenously leading to the development of secondary syphilis. Clinical manifestations of secondary syphilis include a maculopapular rash and ulcerative mucous membrane lesions. It may affect the ear,2 whereby the inner ear is invaded by T. pallidum and which is similar to neurosyphilis. Asymptomatic gastric involvement is thought to be present in nearly all cases of secondary syphilis. In contrast, true syphilitic gastritis is rare, being described in less than 1% of patients with demonstrated secondary syphilis. It may also occur in the third stage of untreated patients. A systematic case review has suggested that in patients with syphilis gastritis, only 13% had a history of syphilis diagnosis and 46% had prior or concurrent clinical manifestations of the disease.3 Clinical and endoscopic findings of syphilis gastritis are non-specific. It can be mistakenly diagnosed as tuberculosis, Crohn’s disease,4 neoplastic disease or lymphoma.5 Epigastric pain/fullness is the most common presenting complaint, but anorexia, nausea and vomiting may also be present. Multiple ulcerations/ulcerative gastritis, nodular mucosa, erosions, large ulcer, thickened folds, narrowing and rigidity, and mass lesions of the antral and prepyloric regions are common endoscopic findings. Most patients were reported to have more than one lesion type. In its late stages, fibrotic narrowing and rigidity of the gastric wall are the most common endoscopic and radiological findings. Upper gastrointestinal series show an ‘‘hourglass’’- or ‘‘dumbbell’’shaped stomach owing to fibrotic narrowing.6 Histology and immune staining combined with serological tests are essential for the diagnosis. T. pallidum
Lai et al. is detected in a smaller but still significant proportion of late disease lesions. T. pallidum detection cannot be used as a reliable indicator of a relatively recent syphilis infection and DNA detection by PCR may be more sensitive for the diagnosis.7 Syphilis gastritis shows good response to treatment with penicillin but surgery is needed in cases of gastric perforation, obstruction, chronic aspiration or strong suspicion of infiltrating tumor or lymphoma. Declaration of conflicting interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Natural Science Foundation of China (Grant Number 81301371), the Guangdong Natural Science Foundation (Grant Number 2014A030313350).
725 References 1. World Health Organization. Report on global sexually transmitted infection surveillance. Geneva: World Health Organization, 2013. 2. Yimtae K, Srirompotong S and Lertsukprasert K. Otosyphilis: a review of 85 cases. Otolaryngol Head Neck Surg 2007; 136: 67–71. 3. Mylona EE, Baraboutis IG, Papastamopoulos V, et al. Gastric syphilis: a systematic review of published cases of the last 50 years. Sex Transm Dis 2010; 37: 177–183. 4. Massironi S, Carmagnola S, Penagini R, et al. Gastric involvement in a patient with secondary syphilis. Dig Liver Dis 2005; 37: 368–371. 5. Adachi K. Syphilitic gastritis mimicking gastric neoplasms. Dig Liver Dis 2011; 43: 748. 6. Jones BV and Lichtenstein JE. Gastric syphilis: radiologic findings. AJR Am J Roentgenol 1993; 160: 59–61. 7. Palmer HM, Higgins SP, Herring AJ, et al. Use of PCR in the diagnosis of early syphilis in the United Kingdom. Sex Transm Infect 2003; 79: 479–483.
