Dermatology Online Journal

Osseous and meningeal involvement in secondary syphilis
Kendall M Egan MD, Michelle C Walters MD
Dermatology Online Journal 18 (4): 1

Department of Dermatology, Naval Medical Center San Diego, San Diego, California

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Abstract

Osseous involvement, although typically described in congenital or tertiary syphilis, has rarely been reported in secondary syphilis. Spirochetes are transported to the medullary cavity or within the deep periosteal vasculature via hematological spread and may be seen in biopsies of the osseous lesions. The skull, shoulder girdle, and long bones are most commonly affected. Patients present with bone pain, which may manifest as headaches or shin splits, depending on the affected bone. This case illustrates the importance of including secondary syphilis in the differential diagnosis of a cutaneous eruption accompanied with headaches. Although the CT scan and CSF testing were negative, the MRI showed osseous and meningeal involvement.

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Case report

A 41-year-old otherwise healthy male presented with a 2-month history of a diffuse asymptomatic papular skin eruption and headaches, localizing to a subtle tender nodule on his right scalp. A prior workup by the neurology department, including a negative head CT, failed to identify an etiology. Recent travel included a deployment to Afghanistan six months prior to the onset of symptoms. He denied any high risk sexual behavior or illicit drug use.

Figure 1	Figure 2
Figure 1. Multiple red-brown firm papules ranging in size from 5 mm to 20 mm were noted on his trunk. Figure 2. An immunohistochemical stain for Treponema pallidum was positive for spirochetes (perivascular).

On physical examination, the patient was well appearing and afebrile. Multiple red-brown firm papules ranging in size from 5 mm to 20 mm were noted on his trunk (Figure 1). Palms, soles, mucous membranes, and genitalia were spared and there was no lymphadenopathy. The majority of the skin papules were smooth and indurated without scale, although a few lesions did have minimal scale and hemorrhagic crust. Rapid plasma reagin (RPR) and HIV were negative. Histologic examination revealed a lichenoid infiltrate with elongated rete ridges and numerous plasma cells. An immunohistochemical stain for Treponema pallidum was positive for spirochetes (Figure 2). Repeat RPR with dilutions and Treponema pallidum antibody, IgG, were both reactive. Dilutions to prevent the prozone phenomenon are not routinely performed on initial RPR testing at our lab. A subsequent lumbar puncture was negative for VDRL and FTA-ABS. A brain MRI showed localized soft tissue (overlying the right temporalis muscle), calvarium bone marrow, and meningeal enhancement (Figure 3).

Figure 3	Figure 4
Figure 3. MRI showing right-sided meningeal, overlying bone marrow, and soft tissue enhancement. Figure 4. Repeat MRI one month after therapy showing significant improvement with only trace residual dural and calvarial enhancement.

The patient received one IM injection of bicillin 2.4 MU, with complete resolution of his cutaneous lesions and headaches, followed by two weeks of IV penicillin (24 million units continuous infusion per day) because of concern for neurosyphilis and osseous involvement. A second IM injection of bicillin 2.4 MU was given one week after completing IV PCN. Treatment was tolerated well, without a Herxheimer reaction. A repeat MRI (one month after completion of therapy) showed almost complete resolution of previously noted regions of enhancement with trace residual dural and calvarial enhancement (Figure 4). Rapid plasma reagin was retested at 3 months after therapy (> 4 fold decrease; 1:4), and will be tested again at 6 and 12 months. The patient remains asymptomatic without headaches.

Comment

Osseous involvement, although typically described in congenital or tertiary syphilis, has rarely been reported in secondary syphilis. Spirochetes are transported to the medullary cavity or within the deep periosteal vasculature via hematological spread [1] and may be seen in biopsies of the osseous lesions [2]. The skull, shoulder girdle, and long bones are most commonly affected [3]. Patients present with bone pain, which may manifest as headaches or shin splits, depending on the affected bone. Periostitis is the most frequent radiographic finding but marrow enhancement, osteoblastic, and osteolytic lesions have also been described [1, 4]. When plain films are negative, bone scintigraphy or MRI should be considered [1, 5]. Whereas there are no established treatment recommendations for osseous involvement in syphilis, weekly intramuscular penicillin or intravenous penicillin for 2-3 weeks usually results in rapid resolution of symptoms [2].

Neurosyphilis must also be considered in secondary syphilis patients presenting with headaches. Because up to 4 percent of patients with neurosyphilis may have normal CSF findings [6], neuroimaging may be useful when the level of suspicion is high. In this case, dramatic osseous and meningeal involvement was seen on MRI despite negative CSF testing.

This case highlights an unusual presentation of secondary syphilis with osseous and meningeal involvement. Syphilis should be considered in the differential diagnosis of a patient presenting with bone pain and/or headaches accompanied by a cutaneous eruption. Furthermore, MRI imaging may be a useful tool in evaluating neurosyphilis as well as osseous involvement in any stage of syphilis.

References

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2. Kandelaki G, Kapila R, Fernandes H. Destructive osteomyelitis associated with early secondary syphilis in an HIV-positive patient diagnosed by Treponema pallidum DNA polymerase chain reaction. AIDS Patient Care STDs. 2007 Apr;21(4):229-33. [PubMed]

3. Longstretch P, Hoke A, Elroy C. Hepatitis and bone destruction as uncommon manifestations of early syphilis. Report of a case. Arch Dermatol. 1976 Oct;112(10):1451-4. Pini

4. Dismukes W, Delgrado D, Mallernee S, Myers T, Longstreth P, Hoke AW, Elroy C. Destructive bone disease in early syphilis. JAMA. 1976 Dec 6;236(23):2646-8. [PubMed]

5. Thakore K, Viroslav A, Vansant J. Role of bone scintigraphy in the detection of periostitis in secondary syphilis. Clin Nucl Med. 1994 Jun;19(6):536-41. [PubMed]

6. Tramont E.: Treponema pallidum (Syphillis) In: Mandell, Douglas, and Bennett 7th ed. Principles and Practice of Infectious Diseases, Philadelphia, Pa: Churchill Livingstone ElSEVIER; 2010:Volume 2, Section F, Chapter 238:3035-53

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