Oral Manifestations of Syphilis: Report of Four Cases

Abstract

Syphilis is an infectious disease caused by Treponema pallidum. Syphilis can present with an array of oral manifestations at different stages of disease progression. This article reports on four cases of syphilis with oral manifestations diagnosed by oral health professionals. Case 1: 18-year-old female presented with multiple ulcerations and patches involving the hard palate, uvula, retromolar area, and papillary nodules on the tongue. Case 2: 25-year-old male presented with a solitary, exophytic lesion on the anterior tongue. Case 3: 17-year-old female presented with multiple pigmented macules on the palms of hands and soles of feet, as well as multiple exophytic, sessile, soft tissue masses throughout the oral cavity. Case 4: 14-year-old female presented with a solitary, exophytic, verrucous lesion in the incisive papilla area, as well as multiple, coalescing patches involving the soft palate, uvula, and tonsillar areas. All patients were managed by biopsy and serological investigations. Treatment of syphilis was performed at infectious disease clinics with 2.4 million units (MUs) benzathine benzylpenicillin intramuscular (IM) weekly. Oral health professionals need to have knowledge of the oral manifestations of syphilis to ensure that patients are accurately identified and appropriately treated.

Keywords: Treponema pallidum; oral health; oral lesions; sexually transmitted infections; syphilis.

Figure 1

Case 1 clinical presentation of infection and histopathological results from biopsy. (a) Pantomograph demonstrating missing teeth 18, 36, and 37. (b) Multiple ulcerations involving the entire soft palate and mucous patches involving the hard palate and soft palate. (c) Left lateral tongue with two papillary nodules. (d) Right lateral tongue with multiple indurated papillary nodules. (e) Ventral aspect of tongue demonstrating extension of papillary nodules from the lateral borders of tongue. (f) Pseudo-epitheliomatous hyperplasia of the epithelium is evident (hematoxylin and eosin (H&E) magnification ×20). (g,h) Prominent neutrophil exocytosis, spongiosis and atypia (hematoxylin and eosin (H&E) magnification ×100). (i,j) The submucosa has a dense perivascular and perineural lymphoplasmacytic infiltrate accompanied by neutrophils and histiocytes (hematoxylin and eosin (H&E) magnification ×200). (k) A positive hyphae presence was demonstrated (Periodic Acid Schiff (PAS) magnification ×400). (l) The Warthin–Starry stain was positive for spirochaetes. Treponema Pallidum noted intra-epithelial and within the lamina propria.

Figure 2

Case 2 clinical presentation of infection and histopathological results from biopsy. (a) Pantomograph demonstrating all teeth are present; spacing of teeth in the anterior maxilla and mandible; isolated vertical bone loss on the mesial aspect of 22. (b,c) Tongue elevated demonstrating ventral aspect with exophytic, well-defined, whitish in colour, lobulated lesion. (d) Tongue at rest demonstrating exophytic, whitish, lobulated lesion. (e) Protrusion of tongue lesion through diastema between tooth 31 and 41. (f) Hyperplastic squamous mucosa with a dense inflammatory infiltrate (hematoxylin and eosin (H&E) magnification ×40). (g) Dense submucosal inflammation with plasma cells (hematoxylin and eosin (H&E) magnification ×100). (h) Predominantly plasmacytic inflammatory infiltrate (hematoxylin and eosin (H&E) magnification ×400). (i) Positive immunohistochemical reaction with Treponema pallidum.

Figure 3

Case 3 clinical presentation of infection and histopathological results from biopsy. (a) Lips at rest demonstrating multiple pigmented macules. (b) Lips retracted demonstrating pigmented macules not extending beyond the vermillion border of the lip. Generalised physiological pigmentation of inner lower lip and mandibular gingiva noted. (c,d) Soles of the feet presented with multiple pigmented macules and areas of skin exfoliation. (e) Palms of the hands with multiple pigmented macules. (f) Pantomograph demonstrating missing teeth 36, 38, and 48; healing extraction socket tooth 36 area. (g) Exophytic, sessile soft tissue masses on upper lip. (h) Exophytic, sessile soft tissue masses on ventral tongue. (i) Localised, exophytic, sessile soft tissue masses posterior palate in midline. (j) Localised, whitish soft tissue mass at the right inner aspect of lip in close approximation to the commissure. (k) Ulcerated lesion in the buccal mucosa opposite the 37. Areas of leukoedema in left buccal mucosa. (l) Hyperplastic squamous mucosa with a dense mixed inflammatory infiltrate (hematoxylin and eosin (H&E) magnification ×20). (m) Dense inflammation comprised mainly of plasma cells (hematoxylin and eosin (H&E) magnification ×200). (n) Perivascular plasma cells in the submucosa (hematoxylin and eosin (H&E) magnification ×400). (o) Positive staining with Treponema pallidum on immunohistochemistry.

Figure 4

(a–f) Case 4 clinical presentation of infection and histopathological results from biopsy. (a) Pantomograph constructed from CBCT scan demonstrating unerupted 18, 28, 38, and 48; missing 16; and dilacerations of roots of 36 and 37. (b) Areas of scab formation on left and right ala of nose. (c) Solitary, exophytic, sessile, well-defined, verrucous mass at the position of the incisive papilla. (d) Dorsal aspect of tongue with multiple pink papules. (e,f) Multiple, slightly elevated, white patches surrounded by erythema covering the soft palate, uvula, and tonsillar pillars. (g) Papillomatous acanthosis of the squamous mucosa (hematoxylin and eosin (H&E) magnification ×20). (h–i) Dense submucosal lymphoplasmacytic infiltrate (hematoxylin and eosin (H&E) magnification ×40 and ×100 respectively). (j) Perineural plasma cell infiltration (hematoxylin and eosin (H&E) magnification ×400). (k) Perivascular plasma cell infiltration (hematoxylin and eosin (H&E) magnification ×400). (l) Intraepithelial and submucosal staining with Treponema pallidum immunohistochemistry.