Histologic Features of Syphilitic Gastritis: A Rare but Resurging Imitator of Common Diseases

Abstract

Objectives: The range of histopathologic features of gastric syphilis is not well described. Here we describe the clinicopathologic findings of eight patients with syphilitic gastritis.

Methods: A search of our Pathology Data System (2003-2022) and multiple other institutions identified eight patients with syphilitic gastritis. Clinical information, pathology reports, and available slides were reviewed.

Results: Lesions predominated in middle-aged adults (mean age, 47.2 years; range, 23-61 years) with a propensity for men (n = 7). Three patients had a documented history of human immunodeficiency virus. Clinical presentations included weight loss, abdominal pain, hematochezia, fever, dyspepsia, nausea and vomiting, hematemesis, anemia, and early satiety. Endoscopic findings included ulcerations, erosions, abnormal mucosa, and nodularity. All specimens shared an active chronic gastritis pattern with intense lymphohistiocytic infiltrates, variable plasma cells, and gland loss. Prominent lymphoid aggregates were seen in four specimens. The diagnosis was confirmed either by immunostain for Treponema pallidum (n = 7) or by direct immunofluorescence staining and real-time polymerase chain reaction (n = 1). All patients with available follow-up data showed resolution of symptoms after antibiotic therapy (n = 4).

Conclusions: Recognition of the histologic pattern of syphilitic gastritis facilitates timely treatment, prevents further transmission, and avoids unnecessarily aggressive treatment.

Keywords: Treponema pallidum; Gastric pathology; Gastritis; Human immunodeficiency virus (HIV); Lymphoma; Men who have sex with men (MSM); Syphilis.

FIGURE 1

Select endoscopic images of syphilitic gastritis. A, B, Patient 1. A, Multiple gastric ulcers (with brown pigmentation) and diffuse erythema in the entirely examined stomach. B, One large ulcer with raised edges in the gastric fundus. C, Patient 3: single large gastric ulcer in the gastric fundus with heaped edges and surrounding edema. D, Patient 4: red, friable, superficial ulcerations in the gastric body. A, B, Images courtesy of Dr Michael Burkholz. C, Image courtesy of Dr Vivek Kumbhari.

FIGURE 2

Patient 1: a 45-year-old man without a documented history of human immunodeficiency virus or having sex with men. A, B, The biopsy specimens show a destructive pattern of active chronic gastritis with expansion of the lamina propria by an intense inflammatory infiltrate (H&E; A, ×4; B, ×10). C, Higher magnification shows that the infiltrate is composed of lymphocytes, histiocytes, eosinophils, and plasma cells (H&E, ×40). D, Numerous spirochetes are demonstrated by immunohistochemical staining for Treponema pallidum (×40).

FIGURE 3

Patient 2: a 61-year-old human immunodeficiency virus–positive man without a documented history of having sex with men. A, B, The biopsy specimens show almost complete effacement of the mucosa by a marked inflammatory infiltrate identical to that seen in patient 1 (H&E; A, ×4; B, ×10). C, Higher magnification shows that the infiltrate is composed of lymphocytes, histiocytes, eosinophils, and plasma cells (H&E, ×40). D, Numerous spirochetes are demonstrated by immunohistochemical staining for Treponema pallidum (×40).

FIGURE 4

Patient 3: a 40-year-old human immunodeficiency virus–negative man without a documented history of having sex with men. A, B, The biopsy specimens show a full mucosal thickness destructive gastritis pattern (H&E; A, ×4; B, ×10). C, Higher magnification shows the expansion of the lamina propria by a lymphohistiocytic infiltrate with prominent plasma cells, along with mild neutrophilic inflammation of the epithelium (H&E, ×40). D, Numerous spirochetes are demonstrated by immunohistochemical staining for Treponema pallidum (×40).

FIGURE 5

Patient 4: a 59-year-old man without a documented history of human immunodeficiency virus or having sex with men. A, B, The biopsy specimens from this patient also show a destructive chronic active gastritis pattern with prominent lymphoid follicles. No intraepithelial lymphocytes or lymphoepithelial lesions are seen (H&E; A, ×4; B, ×10). C, Higher magnification shows a polymorphous infiltrate composed of lymphocytes, histiocytes, eosinophils, prominent plasma cells, and a focus of intestinal metaplasia (H&E, ×40). D, Immunostain for Treponema pallidum highlights the spirochetes (×40).

FIGURE 6

Patient 5: a 55-year-old woman without a documented history of human immunodeficiency virus. A, The biopsy specimens show a destructive active chronic gastritis pattern with prominent lymphoid follicles. Note the deep inflammatory involvement that includes submucosa. No intraepithelial lymphocytes or lymphoepithelial lesions are seen (H&E, ×4). B, C, Higher magnification shows a polymorphous infiltrate composed of lymphocytes, histiocytes, eosinophils, prominent plasma cells, and foci of intestinal metaplasia (H&E; B, ×10; C, ×40). D, Immunostain for Treponema pallidum highlights the spirochetes (×40).

FIGURE 7

Patient 6: a 35-year-old man without a documented history of human immunodeficiency virus. A, B, Gastrectomy specimen shows a destructive active chronic gastritis with prominent lymphoid follicles and spillover into the superficial submucosa (H&E, ×10). C, Higher magnification shows the prominence of plasma cells (H&E, ×40). D, Specific immunofluorescence staining of pathogenic treponemes with monoclonal antibody. The FITC-labeled mouse antitreponemal 37-kDa monoclonal antibody stain demonstrates numerous spirochetes in thin-section specimens by the use of a ×100 oil objective and a ×10 ocular.