Oral manifestations of syphilis: an alarming trend in Kuwait

Abstract

Introduction

Syphilis, a sexually transmitted bacterial disease, is caused by Treponema pallidum (T. pallidum). The diagnosis of syphilis can be difficult without suspicion, and it’s made through serologic testing or direct detection of (T. pallidum) in biopsies. The stage at diagnosis and neurologic involvement determine the treatment.

Case Series

Eleven patients presented to different governmental clinics in Kuwait. Ten were males, and the patients ranged in age from 21 to 39.5 years old. While one patient had only a peri-anal lesion, the remainder presented with generalized oral/oropharyngeal painful lesions. The oral manifestations consisted of red/violaceous macules that progress into “waxy” mucosal thickening, “Mucus Patches.” Exophytic rough/papillary growth, “condylomata lata,” can develop. Less frequently, mucosal nodularity and “cobble-stoning,” similar to those seen in granulomatous processes, is observed. One peri-anal lesion from a male patient was only examined histologically in consultation and was clinically ulcerated pyogenic granuloma-like. Treponema IHC testing confirmed the diagnoses, while Warthin starry histochemical testing done on at least 5 cases was negative. Histologically, the lesions exhibited certain general diagnostically helpful features with different degree of manifestation across all biopsies. They are the presence of plasmacytic infiltrate submucosally, combined with the presence of neutrophils in the mucosal lining. Hyperplasia of the mucosa is helpful as well and can range from slight elongation of the rete ridges to a papillary/exophytic hyperplasia. The submucosal plasmacytic infiltrate also varies in the percentage of lymphocytes present and may extended deeper and with a perivascular pattern.

Conclusion

Syphilis can present a diagnostic challenge to unsuspecting diagnosticians. Oral lesions may be the first sign; thus dentists are on the frontline and must be familiar with it. Pathologists must be quick to test with Treponema IHC when certain histologic signs are observed in the biopsies. If misdiagnosed, or left untreated, the consequences can be a public health catastrophe.