Cas Clinique / Case Report

Mdecine Orale / Oral Medicine

ORAL TERTIARY SYPHILIS : A CASE REPORT

Deepa MS* | Anita Balan** | Sunil S*** | Bifi Joy****

Abstract
Currently, tertiary syphilis is very rarely seen. This paper describes a case of benign tertiary syphilis. The lesion appears as
a solitary hypertrophic lesion on the dorsum of the tongue. The
oral aspects of tertiary syphilis and the importance of considering this pathologic entity in the differential diagnosis of oral
lesions are highlighted.

Rsum
Actuellement, la syphilis tertiaire est trs rarement observe. Cet
article dcrit un cas de syphilis tertiaire bnin. La lsion apparat comme une lsion hypertrophique solitaire sur le dos de la
langue. Les caractres oraux de la syphilis tertiaire et limportance denvisager cette entit pathologique dans le diagnostic
diffrentiel des lsions buccales sont mis en vidence.

Keywords: Spirochetes Treponema pallidum - tertiary

syphilis.

Mots-cls: spirochtes Trponme pallidum syphillis

tertiaire.

* Prof.
Head Dept of Oral Medicine,
Azeezia College of Dental Sciences
and Research, Kollam, Kerala, India
docdeepams@yahoo.co.in

** Prof.

Head Dept of Oral Medicine &

Radiology
Governmental Dental College,
Calicut, Kerala, India

*** Prof.

Dept of Oral & Maxillofacial

Pathology,
Azeezia College of Dental Sciences
and Research, India

**** Ex PG Student

Dept of Dermatology,
Medical College, Trivandrum, India

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Introduction
Syphilis is a sexually transmitted
disease (STD) produced by Treponema
pallidum, a microaerophilic spirochete
which mainly infects humans [1]. This
infection can also be transmitted in
utero, and rarely by blood transfusion
or non-sexual contact [2].
Syphilis has two main clinical
stages: early and late. Early or infectious syphilis (recently acquired, or of
less than two years duration) is the
more contagious stage, and includes
the primary and secondary forms and
the early latent period [3]. In tertiary
syphilis, which is extremely rare, manifestations may take up to 10 years to
appear and then present themselves as
benign tertiary (gummatous lesions),
cardiovascular syphilis, or neurosyphilis [4].
Fortunately, manifestations of tertiary syphilis have become rare due
to the development of programs that
control sexually transmitted diseases
and the inadvertent therapy with antibiotics administered for other pathologic conditions.
In this report, we describe a case of
benign tertiary syphilis represented by
a solitary lesion of the tongue.

Case Presentation
A 65-year-old lady was referred
to the Department of Oral Medicine
& Radiology for the evaluation of a
solitary painless ulcer on the dorsum of tongue from the Department
of Venerology, Medical College,
Trivandrum, Kerala.
Her medical history was uneventful. She had increased salivation for
the past 5 years.
Her husband died 17 years ago. She
had 4 healthy children.
The clinical examination didnt
reveal any active skin or genital lesion.
She had a solitary painless, 2x2cm
well-defined ulcer in the middle of
dorsum of tongue (Fig. 1) with a pale
granulation tissue at the base. There
was no fluid exudation on pressure.

Fig 1: Clinical photograph showing ulcer

on the dorsum of tongue.

Fig. 2: Photomicrograph showing nonspecific inflammation of the connective

tissue, H& E section, 10X.

Cervical and generalized lymphadenopathy was not detected.

Subsequent hematological, serological and histopathological investigations were carried out. Hematological
examinations were within normal
limits. Blood serologic tests for syphilis (STS) showed positivity in 1 of
32 dilutions. Treponema pallidum
haemagglutination (TPHA) test was
positive; hepatitis B surface antigen (HBsAg) and the enzyme-linked
immunosorbent assay (ELISA) were
negative.
Histopathological
examination
revealed only a chronic nonspecific
inflammation (Fig. 2).
Based on the results of serological examination, the patient was diagnosed as having a gummatous ulcer
on the tongue and was put on penicillin therapy as intramuscular injection
PP 12 lakh units- daily for 12 consecutive days. A resolution of the lesion
was noticed 2 weeks after the initiation
of the penicillin therapy and blood STS
became non-reactive after 3 months.

incubation period of up to 90 days, a

chancre develops at the site of inoculation. These ulcers may be solitary or
multiple, and generally heal spontaneously without treatment within 38
weeks.
Syphilis gives rise to a wide spectrum of orofacial manifestations [5-7].
However the exclusive oral localization, not associated with general
manifestations, is uncommon [8]. The
various orofacial manifestations of the
different stages of syphilis are shown
in table 1 [9].
Gummas tend to arise on the hard
palate and tongue; although very rare,
they may occur on the soft palate,
lower alveolus and parotid gland.
The signs and symptoms of primary and secondary syphilis resolve
spontaneously. Patients enter then
the latent stage of infection [10, 11].
Manifestations of tertiary syphilis may
appear after several years of non-treatment with cardiovascular and neurologic involvements including severe
manifestation of general paresis and
aneurysm of aorta.
Benign tertiary syphilis is characterized by the tissue immunological
reaction that leads to a specific lesion
designed as gumma. These lesions are
destructive granulomatous inflammation that may develop in any organ [4].
In the present case, the lesion observed on the dorsal surface of the tongue
was a gummatous inflammation of
tertiary syphilis.
Conclusive diagnosis of syphilis
infection is based on confirmation of

Discussion
Infective syphilis is caused by
the spirochete Treponema pallidum.
Transmission occurs via close contact
with an infected lesion, which usually
occurs on the genitals.
Following contact, Treponema pallidum penetrates the genital or oral
mucosa, multiplies at this site of entry,
and systemically spreads via the lymphatics and blood. After an average

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Mdecine Orale / Oral Medicine
Stage of disease

Orofacial manifestations

Primary

Chancre
Non-tender cervical lymphadenopathy

Secondary

Mucous patch
Rubbery cervical lymphadenopathy
Maculopapular eruptions
Moth-eaten alopecia
Syphilitic leukoedema - patches of hypopigmentation
Condylomata lata

Tertiary

Gumma (palate and tongue)

Osteomyelitis
Atrophic and interstitial glossitis
Syphilitic leukoplakia
Syphilitic sialadenitis
Trigeminal neuropathy (Hitzigs Syndrome)
Argyll-Robertson pupil

Congenital Syphilis

Moons / Mulberry molars

Hutchinsons incisors
Facial deformity - High arched or gothic palate
- Maxillary hypoplasia Bulldog jaw
- Saddle shaped deformity of nose
- Frontal bossing
Mucous patches
Rhagades (scars radiating from lips)
Cranial neuropathies

Table 1: The orofacial manifestations

of different stages of syphilis [7].

the clinical signs and symptoms with

laboratory tests [11]. Treponema pallidum
can be identified in lesions by dark
field microscopy or direct immunofluorescence, but usually serological
confirmation is necessary [12].
The diagnostic serologic tests for
syphilis include tests that detect antibodies to non-specific treponemal
antigens - the Rapid Plasma Reagin
(RPR), Venereal Disease Research
Laboratory tests (VDRL) and tests that
detect antibodies specific to Treponema
pallidum the Treponema pallidum
hameagglutination assay (TPHA) and
fluorescent treponema antibodies
absorbed assay (FTA-Abs).
The non-specific antibody tests are
inexpensive, rapid screening tools and
markers of disease activity. The specific tests are more sensitive than the
non-specific assay. FTA-Abs detects
antibodies to Treponema pallidum in the
early stages of infection [12, 13]. In the
secondary stage, microorganisms may
be detected by special silver impregnation techniques and direct fluorescent
antibody testing.

Meyer and Shklar reported the

features of primary and secondary
syphilis to be essentially non-specific
and the tertiary lesion to be the most
obviously granulomatous and populated by Langhans-type giant cells [14].
The histo-pathologic features in the
primary lesions consist of an ulcerated
epithelium. The underlying connective
tissue may show moderate vascularity
with intense chronic inflammatory cell
infiltration, predominantly lymphocytes and plasma cells with perivascular pattern. In secondary syphilis, the
features include hyperplastic epithelium and the connective tissue shows
perivascular infiltration with chronic
inflammatory cells. In tertiary lesions,
ulcerated epithelium with inflammation of connective tissue and foci of
granulomatous inflammation with
histiocytes and giant cells are noticed
[14-16].
Features of c/c granulomatous
inflammation
without
significant
necrosis are typical of early nodular lesions of tertiary syphilis and
the sparse numbers of plasma cells

can mask the diagnosis [17]. Tertiary

lesions are only sparsely populated
with spirochetes [18]. Easy, consistent
and reliable identification of Treponema
pallidum, however remains problematic.

Conclusion
Syphilis is an infectious disease
presenting stages associated with
specific oral lesions. Therefore, health
professionals should be familiar with
the different syphilis oral manifestations at each stage and be prepared to
refer any suspected patient for further
evaluation.

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IAJD Vol. 5 Issue 2

Cas clinique | Case report

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