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Syphilis:
Discussion
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The radiographic and pathophysiologic features of early acquired syphilis are discussed. Bone changes occur in early acquired syphilis and should not be confused with gummas of late syphilis. The radiographic findings are protean and may exist without a clinical history of a cutaneous lesion. The skull, clavicle, and tibia are the sites most frequently involved.
Osseous
syphilis
was
diagnosed Wasserman
and from 1 940
bone
[71
disease
1 932
patients
Introduction from
with
1 91 9-1
early
acquired
syphilis
lesions in a total
over
of 52
a 21 year
period
demoncases,
The
and ture
osseous
have and not
changes
been on
of early
emphasized bone
acquired
in recent disease
syphilis
radiologic We ( 1-3j.
are
rare
litera-
strated including
textbooks
recently
in 0.1 5%-8.7%
of patients
examined during
this disease.
that
occurred stage of
Clinical Features
Bone
primary Case Report dary veloped [7]. The skin
changes
chancre eruption. with the degree
occur
to as late In cutaneous of
as early
several bone soft
as
6 weeks
after bone is swelling,
after
the changes
the
de-
seconsyphilis more
until 4 weeks prior to admission when he noted constant aching pain in the calves with slight muscle weakness and aching and tenderness of the ankles. He noted an eruption on the palms and soles at the time his muscle and joint pain began. There was no history of syphilis
A 35-year-old
black
male
was
well
of secondary usually
severe
ically
than
there
the
may
clinical
be pain,
symptomatology
tissue
[27-29]. symptoms.
secondary and soles.
ClinThe
syphilis It must
tenderness,
headache,
fever,
and
other
constitutional
contact
or treatment
for syphilis.
Physical
examination
showed
a well nourished patient in no acute distress. There were hyperpigmented keratotic macules on the palms and soles bilaterally.
syphilis.
The antibody
There
of
remainder absorption
osteomyelitis or secondary
lesions
and
Radio-
and,
in fact,
may
develop
a short
serologic lesions
time
test occur
after
for [5.
blood
syphilis 1 71.
at a 1 :64 osteolytic
dilution.
lesions
in the
cortex of the tibiae, fibulae, ulnae, and radii (figs. 1 and 2) with solid periosteal reaction in several locations. There was minimal destruction of the proximal aspect of the second metacarpal along with solid periosteal reaction (fig. 3). No lesions were present in the skull, clavicles, other long bones, ribs. spine, or feet. Biopsy of the left fibula disclosed necrotic bone with inflammatory cell infiltrate composed mostly of mature plasma cells. The vascularity was prominent and the endothelial cells were swollen and pleomorphic. Spirochetes were identified within the inflammatory cell exudate. The pathologic diagnosis was syphilitic periostitis and osteitis.
and mucocutaneous
1 -3 months after may the spirochetes canals, and
lesions
primary
of seconchancre. hema-
be disseminated
togenously
teum, [30]. and canals of bone Several
throughout
investigators by way of and
the body
[25, blood
and
found
space state in
in the
that the
periossyphilis space
medullary 31 , 32]
of all bones
in the vessels
medullary
spreads
Haversian
The patient was treated with 12 million units of procaine penicillin intramuscularly over a 10 day period. During hospitali-
and molluscum
contagiosum.
Spirochetes induce a perivascular response followed by muscularis atrophy, endothelial proliferation, and subsequent endarteritis obliterans [17, 30]. These vascular changes are the cause of osteochondritis, periostitis, osteitis, or osteomyelitis depending on which part of the
bone is involved. The vascular changes lead later to secon-
Received March 15, 1976; accepted after revision Department of Diagnostic Radiology, Hahnemann reprint requests to M. E. Kricun. Am J Ro.ntg.nol
June
and Hospital.
230
North
Broad
Street,
Philadelphia.
Pennsylvania
19102.
Address
127:789-792.
1976
789
if,
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EARLY
ACQUIRED
SYPHILIS
791
dary
late
ischemia
syphilis [17].
and
caseation
necrosis-the
gumma
.:
.
of
C
2. Greenfield
delphia,
GB: Radiology
Lippincott. 1975
of Bone
Diseases,
2d
ed.
Phila-
Distribution and clavicle, are the syphilis. followed sites Other by the most sites nasal and tibia, humerus, involved with less
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frequently reported
frequency
bones palate, knee,
are
of the
the
hands ileum, Features
femur,
and ischium,
fibula,
feet,
sternum,
bones, spine.
ribs,
facial
scapula,
bones,
Radiographic
of bone depends
and the
involved.
osteomyelitis, and osteitis manifested by periosteal reaction, bone destruction, or sclerosis may occur alone or in combination and may be localized or diffuse. Periosteal reaction is usually laminated or solid, but can be perpendicular simulating an osteosarcoma [1 7, 28, 33]. Osteomyelitis causes osteolytic changes in the cortex and medullary space, usually with an aggressive pattern of bone destruction. Skull lesions appear as irregular areas of bone destruction; the outer table is more frequently involved than the diploae and inner table. There may be soft tissue swelling and wavy periosteal reaction [7]. In the long bones sequestration [1 7. 31 ], pathologic fracture [6, 31 , 34], epiphyseal separation [31 ], and even syphilitic arthritis [32] may occur as sequelae. Sequestra in syphilis are difficult to visualize radiographically because they are small and usually occur in cancellous bone [17]. It should be stressed that the destructive lesions in early acquired syphilis are those of osteomyelitis and do not represent gummas.
Differential Diagnosis
3, MUrray RO, Jacobson HG : The Radiology of Skeletal Disorders. Exercises in Diagnosis. Baltimore, Williams & Wilkins, 1971 4. Lancereaux E: Les ost#{233}ites syphilitiques. Ann Dermatol Syphiligr (Paris) 7 :26 1 , 1886 5. Nitchew L: A propos des ost#{233}o-p#{233}riostites syphilitiques pr#{234}coces. Ann Malad Vener 27:600-605, 1932 6. Gougerot MM, Mathieu P. Jais: Fracture spontan#{233}e de Ia clavicule au debut de Ia syphilis secondaire. Ann Ma!ad Vener27:31, 1932 7. Reynolds FW, Wasserman H: Destructive osseous lesions in early syphilis. Arch Intern Med 69:263-276, 1942 8. Bauer MF, Caravati CM: Osteolytic lesions in early syphilis. Br J Vener Dis 43: 1 75-1 77, 1967 9. Bloom P: Destructive osteitis and facial paralysis in secondary syphilis. Arch Dermato! Syph 29:940, 1934 10. Burrows HJ: Pathological fracture of the humerus complicating late secondary syphilis. Br J Surg 24:452, 1937 1 1 . Cabanel G. Phelip X, Gintz B: Ost#{233}ite cranienne lacunaire de Ia syphilis secondaire. Presse Med 79:1755-1756, 1971 1 2. Dillingham FH, McCafferty LK: Bone syphilis. Am J Syph 10:378-382, 1926 13. Exley M. Newton AW: Osseous syphilis. N Eng!J Med 234: 661-664, 1946 1 4. Farina A: Su un caso di osteomielite gummosa nel periodo precoce della lue. G Med Mi! 87:59, 1939 1 5. Lefkovits AM, Cross KR: Bone lesions in early syphilis. Am J Clin Patho! 1 6:693-700, 1946 1 6. Mandelbaum H. Saperstein AN: Transmission of syphilis by blood transfusion: a case of acute gummatous osteomyelitis.JAMA 1 7. Metcalfe 106:1061, JW: Syphilitic 1936 osteoperiostitis-skull, ribs, and
phalanges. 1 8. Newman
during
USN Med Bull 49:528-535, BA, Saunders HC: Skeletal secondary syphilis. NY State
JDJ: Uncommon complications
1949
system manifestations Med J 38:788-795,
of early syphilis.
1938
19. Parker
Hepatitis, periostitis. iritis with papillitis. and meningitis. Br J Vener Dis 48:32-36, 1972 20. Pi#{225}n HC. Frazier CN: Transfusion syphilis with widespread
osteomyelitis and cutaneous lesions of an erythema multi-
Syphilis has long been called the great imitator, and the differential diagnosis of bone changes reflects this statement. Aggressive-appearing osteomyelitis with or without periostitis may simulate pyogenic osteomyelitis, metastatic
disease, histiocytosis, lymphoma, leukemia, tuberculosis,
21 22. 23.
fungal
34-36]. coma
disease,
and
Ewings
sarcoma
may
[7,
1 3, 1 7, 27,
osteogenic
29,
sar-
simulate
ACKNOWLEDGMENTS Drs.
primary
Hugh
care
Bennett
and
and
follow-up
Ronald
of this
Shore
patient.
for
Carol
25. 26.
Garifo
for excellent
secretarial
assistance.
REFER ENCES
1. Edeiken Bone.
Roentgen
Diagnosis
of
Diseases
of
27.
Williams
& Wilkins,
1973
forme type. Chin Med J 57:301 , 1940 Squires JB, Weiner AL: Osteitis in early syphilis: report of a case. Arch Dermato! Syph 39:830, 1939 Tauber EB, Goldman L: Syphilitic anemia with diffuse osteitis and superinfection. Am J Syph Neurol 1 9:339, 1935 Thompson AG, Leedham CL, Hailey H: Osteomyelitis of the skull in early syphilis. Report of two cases probably influenced by trauma. Am J Syph Gonn Vener Dis 33:34-42, 1949 Thompson AG. Preston RH : Lesions of the skull in secondary syphilis. Am J Syph Gonn Vener Dis 36:332-341 , 1952 Truog CP: Bone lesions in acquired syphilis. Radiology 40: 1-9, 1943 Wile UJ, Welton DG: Early syphilitic osteomyelitis with a report of two cases. Am J Syph Gonn Vener Dis 24:1-12, 1940 Galvin AH: Syphilis of the osseous system. Am J Syph 12:187-193, 1928
while
not
cited.
have
been
included
for
the
792
EHRLICH
AND
KRICUN
28. Sante
LA: Radiographic
manifestations
of
syphilitic
diseases
39.
ofbone.AmJSyph
12:510-516,
1928
Luetic 1962
lumbar
spondylitis.
Proc
R Soc
Med
29. Ungerman
simulating 229. 1938
AH,
Vicary
WH.
disease.
Eldridge
Am of
WW:
Luetic
malignant
osteitis 40:224-
30. Robbins
SL:
1974 JS. Boyd
Basis syphilis.
Philadelphia, J 29:371
-
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Saunders,
31
Syphilis
Surg
of the bones
46:199-205,
and some
1907
radiographic
findings.
Ann
33. Skapinker
34.
S. Minnaar
D: Syphilitic
disease
HC, Kampmeier RH: The bone lesions in acquired syphilis. South Med J 36:556-559, 1943 41 . GW. Lingley JR: Roentgenologic manifestations of syphilis. N EnglJ Med 217:983-987, 1937 42. Karaharju EO. Hannuksela M: Possible syphilitic spondylitis. Acta Orthop Scand 44:289-295, 1973 43. Nathan AS, Lawson W: Syphilitic osteomyelitis of the mandible. Oral Surg 1 7:284-288, 1964 44. Rost GS: Roentgen manifestations of Bejel (endemic syphilis) as observed in the Euphrates River Valley. Radiology 38:320-325,
45. Roy
syphilis.
40. Francis
in the Bantu. J Bone Joint Surg 33-B:578-583, 1951 Olmstead EG: Gummatous osteomyelitis with pathologic fracture complicating general paresis. Am J Syph 32:243-
1942
Laird SM: Acute
Dis 49:555,
RB,
periostitis
in
early
acquired
syphiClinical bones
250,
1948
35. Carman AD: A review of the roentgenology of syphilis. Am JSyph 2:297-343, 1918 36. Johns D: Syphilitic disorders of the spine. J Bone Joint Surg 52-B:724-731, 1970 37. Alexander U, Schoch AG: Osseous syphilis. Am J Syph Gonn Vener Dis 26:397-406, 1942 38. Bailey GG: Manifestations of bone syphilis. Urol Cut Rev 49:11-12, 1945
1973 46. Stewart DM: Roentgenological manifestations lis. Am J Roentgenol 40:2 1 5-223, 1938 47. Stokes JH, Beerman H, Ingraham NR Jr: Syphilology, 3d ed. Philadelphia, Saunders,
Br J Vener 48. Wile UJ, Senear FE: A study of the Am involvement Sci
in bone Modern
1944
of the
in early
syphilis.
J Med
1 52:689-693,