JRSM >
Volume 97, Number 2 >
Pp. 79-80
Department of Dermatology, NDMVPS Medical College and Research Centre, Nashik,
Maharashtra State, India
1 Department of Community and Family Medicine, The Chinese University of Hong
Kong and Prince of Wales Hospital, Shatin, Hong Kong SAR, China
Correspondence to: Dr Vijay Zawar, Shreeram Sankul Opp. Hotel Panchavati, Vakilwadi, Nashik-422002, Maharashtra State, India E-mail: vijayzawar{at}yahoo.com
In patients whose symptoms have no obvious venereal connection, few clinicians elicit a history including the sexual behaviour of spouses or partners.
CASE HISTORY
A woman aged 30 sought advice about lesions in the oral cavity, present for three months. They had begun as tiny grey patches inside the cheeks and lips. In the past month they had increased rapidly in size, causing burning sensations with eating. For two months she had also been experiencing intermittent bony pains around the elbows and wrists. There was no history of fever or other systemic symptoms in the past 2 years, or of genital ulcer, abnormal vaginal discharge or rash. She had not engaged in sex outside marriage but could not say whether her husband had any history of genital ulcer or extramarital exposure. Before coming to us, the patient had consulted two general practitioners and one physician about the mouth lesions. The prescribed medications included topical steroids, paints and analgesics, but full details are not known.
On examination, there were multiple grey-white, fleshy, non-indurated plaques on the mucosal surfaces of the upper and lower lips as well as on the buccal mucosa of the cheeks extending inside from the angles of the mouth. Snail-track ulcers were not seen and the tongue, hard palate and tonsils appeared normal. There was no regional lymphadenopathy but enlarged non-tender supratrochlear nodes were palpable bilaterally. On gynaecological examination nothing abnormal was detected—specifically, no genital ulcer, vulval lesions, or enlargement of inguinal lymph nodes. The skin, eyes, and joints were likewise free from obvious abnormality. Laboratory tests were unrevealing apart from a Venereal Disease Research Laboratory (VDRL) test positive at a titre of 1:64. We examined the accompanying husband. When assured that his information would be confidential, he volunteered a history of a single, large, painless and self-resolving genital ulcer eighteen months previously, which had developed three months after sexual contact with a sex worker. There was a papery thin, wrinkled, atrophic scar over the dorsal aspect of the penis. His VDRL test was also positive at a titre of 1:32.
We considered the possibility that the oral lesions in the wife were primary chancres, but the couple had not engaged in oral sex and the high VRDL titre was against this. They clearly had secondary syphilis and we gave deep intramuscular benzathine penicillin 2.4 megaunits to both. When the wife came for follow-up ten days later the oral lesions had resolved completely, though with post-inflammatory hyperpigmentation in places. We prescribed two more weekly doses of benzathine penicillin to the couple, whom we planned to follow clinically and serologically for 2 years. We had in mind the need to examine their cerebrospinal fluid if the VDRL titre did not fall fourfold within three months, to rule out neurosyphilis (for which benzathine penicillin may not be sufficient treatment). Unfortunately they were lost to further follow-up.
COMMENT
A noteworthy feature of this case is the failure of three doctors to suspect the true cause of the mucous patches and take a full sexual history. Perhaps they thought the patient at low risk, forgetting that monogamous sex gives no protection against extramarital activity by the partner.
Secondary syphilis is characterized by multisystem effects developing in the first 2 years after infection.1-5 The commonest is a non-pruritic rash, typically on the palms and soles. Other manifestations are mucous patches, condylomata lata, patchy alopecia, hepatosplenomegaly, and generalized lymphadenopathy. Fever, headache and malaise are commonly present, and rare features include meningitis, hepatitis, iridocyclitis, arthritis and periostitis. In the present case, a possible reason for the absence of florid systemic features may be antimicrobials prescribed or dispensed by the general practitioners, though we have no details.
Intraoral manifestations of secondary syphilis need to be recognized not only by general practitioners but also by specialists including dentists6 and otolaryngologists.7 Recognition is vital, not least because the lesions are teeming with spirochaetes and highly infectious. Contacts must be traced. Moreover, if the patient is misdiagnosed as having a condition such as gingivostomatitis, antibiotics may be prescribed in doses that achieve remission without complete eradication of the disease. Then, without long-term follow-up, he or she is at risk of grave tertiary complications.
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