142Indian Journal of Dental Research, 24(1), 2013

Atypical oral manifestations in secondary syphilis

Puneeta Vohra Singh, Ranjit Patil1

Received : 09-11-09
Review completed : 01-07-10
Accepted : 16-09-10

ABSTRACT
Sexually transmitted diseases (STDs) are posing a growing public health problem on a global 
and national scale. Syphilis is one of the common STD. The dentist is most likely to come 
across associated oral manifestation of the disease. This is a case report of 60‑year‑old male 
patient who presented with multiple erythmatous lesions with shallow ulcerations and crusted 
appearance on the lip, mimicking few mucocutaneous lesions of oral cavity. He gave history of 
sexual exposure;further work up revealed it to be a case of secondary syphilis.

Key words: Oral manifestations, secondary syphilis, sexually transmitted diseases

Departments of Oral Diagnosis, 
Medicine and Radiology, 
PDM Dental College 
and Research Institute, 
Bahadurgarh, Haryana,  
1Department of Oral Medicine 
and Radiology, Faculty of Dental 
Sciences, King George Medical 
University, Lukhnow, 
Uttar Pradesh, India

CASE REPORT

A 60‑year‑old unmarried Indian male reported to the 
Department of Oral Diagnosis Medicine and Radiology with 
a chief complaint of bleeding from lips since 15 days. He 
also complained of fever, pain, weight loss, loss of appetite, 
weakness and numerous itchy erythematous lesions on 
hands, forearms, back and chest since 15 days. The patient 
gave past history of similar skin lesions 2 years back, which 
subsided after the treatment. The patient also gave history 
of unprotected sexual contacts with multiple commercial 
sex workers.

On general examination, the patient was weak, cachexic, 
poorly nourished, thin built with normal posture and gait. 
Extraoral examination revealed excoriating skin lesions seen 
on both hands, lower forearms, forehead, chest and large 
healed lesion with a scar formation on lower back region 
[Figure 1].

On intraoral examination, there were multiple erythematous 
lesions with shallow ulceration on lower lip and hemorrhagic 
crusted appearance on right side of lower lip. A hemorrhagic 
lesion on hard palate, along with melanin pigmentation 
on dorsal surface of tongue and buccal mucosa was also 
noticed [Figure 2]. Based on this atypical picture, we came 
to differential diagnosis of pemphigus, erythema multiforme, 
benign mucous membrane pemphigoid, HIV associated 
lesions and syphilis.

The patient was advised blood investigations including 
complete blood count, protein electrophoresis, antinuclear 
antibody test, Venereal Disease Research Laboratory 
(VDRL) test, enzyme‑linked immunosorbent assay (ELISA) 

Address for correspondence: 
Dr. Puneeta Vohra Singh 
E‑mail: drpuneeta_mithi@yahoo.co.in

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DOI:  
10.4103/0970-9290.114928

Syphilis is a chronic infectious sexually transmitted disease 
(STD), caused by the spirochete Treponema Pallidum, 
first recognized in Europe in 1490s, and has been related 
to the return of Christopher Columbus. At that time, 
syphilis was an acute disease that caused destructive skin 
lesions and early death; but, since then, it has become 
milder, with a more protracted and insidious clinical 
course due to widespread use of antibiotics. In the past 
three decades, there has been widespread upsurge due 
to pandemic of Human Immunodeficiency Virus (HIV). 
As per World Health Organization reports, more than 
12 million new cases of venereal syphilis occur every 
year, affecting 6.4 million people in Asia Pacific regions 
and more than 90% of them in developing countries. 
Syphilis has florid features sometimes, but there may be 
marked periods of latency in others. The presence of oral 
manifestations may be a feature of all stages of syphilis 
and often may be its first clinical manifestation as there is 
a renaissance of old disease with oral implications.[1,2] This 
is a case report of atypical oral manifestation of secondary 
syphilis.

shOrt cOmmunicatiOn

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Atypical oral manifestations in secondary syphilis Singh and Patil

Indian Journal of Dental Research, 24(1), 2013143

for HIV and HBsAg antigen for Hepatitis B, biopsy with 
direct immunoflourescence (DIF) and dark field microscopy 
[Figure 3]. All the tests were found to be normal; DIF 
was negative as only lymphocytes and plasmocytes with 
endothelial swelling were visible; VDRL was seen to be 
reactive with high titer of 1:64 and spirochetes were visible 
in dark field microscope. Thus, on the basis of personal 
history, clinical manifestation and positive VDRL test 
and biopsy from lesion site, final diagnosis of secondary 
syphilis was made. Other more specific investigations like 
Treponema Pallidum Hemagglutination Assay (TPHA) 
and Treponema Pallidum Particle‑Agglutination Test 
(TPPA) were not done due to nonavailability and financial 
constraints.

The patient was treated with 2.4 MU benzathine penicillin  
every week for 1 month. He was also given betamethasone 
4 mg IM each week for 2 weeks to avoid Jarisch‑Herxheimer 
reaction. All the lesions healed completely after 1 month 
of medication, with no reoccurrence after 3 months of 
follow‑up [Figure 4]. VDRL test was repeated and the titer 

decreased to 1:32. Patient was counseled and advised to be 
on regular follow‑up after every 3 months.

DISCUSSION

Syphilis is a STD caused by T. pallidum infection and manifests 
with skin, mucous membrane, and systemic lesions. Data from 
around the world indicate an increasing prevalence of STDs. 
Another alarming situation in the context of syphilis is that 
its manifestations are also being bizarre or atypical. This wide 
array of manifestations has given syphilis the reputation as a 
great imitator. In the last 20 years, there has been a gradual 
increase in new cases of syphilis.[3]

There are four stages of occurrence of acquired syphilis in 
which primary syphilis typically presents as a solitary, painless 
chancre, whereas secondary syphilis can have a wide variety 
of symptoms, especially fever, lymphadenopathy, rash and 
genital or perineal condyloma latum; all clinical manifestations 
subside and infection is apparent only on serologic testing. 

Figure 1: Excoriating scaly skin lesions on lower forearms
Figure 2: Multiple erythematous lesions with shallow healed ulcerations 
and hemorrhagic crusted appearance on lower lip

Figure 3: DIF showing dense inflammatory infiltrate composed of 
lymphocytes and plasmocytes with endothelial cell swelling

Figure 4: Post‑treatment photograph of patient after 1 month of 
medication

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Atypical oral manifestations in secondary syphilis Singh and Patil

144Indian Journal of Dental Research, 24(1), 2013

Late or tertiary syphilis can manifest years after infection as 
gummatous disease, cardiovascular disease, or central nervous 
system involvement which can be finally manifested as 
neurosyphilis a final or quaternary stage of disease.

The eruption of secondary syphilis has certain characteristics 
which help to identify and distinguish it from other 
lesions. Typical mucous membrane lesions tend to be oval, 
serpiginous, raised erosions or ulcers with an erythematosus 
border. There is an overlying gray or silver membrane. 
Sometimes, these lesions can appear as leukokeratosis and 
involve the tongue, the mucosal lip, or the palate. Usually, 
the spirochetemia of secondary syphilis is associated with 
systemic symptoms and a cutaneous eruption; rarely, there 
may be spirochetemia without cutaneous manifestations. The 
oral cavity is the most common extragenital site of infection, 
although isolated oral ulcerations in secondary syphilis are 
unusual.[3] In fact, there are only a few reports of secondary 
syphilis presenting with isolated oral lesions.[4] In contrast 
with oral lesions of primary syphilis, which tend to be 
solitary, painless, indurated ulcers, oral lesions of secondary 
syphilis are typically painful and multiple. They are usually 
accompanied by a concomitant cutaneous eruption.[5,6]

The differential diagnosis of oral lesions of secondary syphilis 
includes erythema multiforme, stomatitis, pemphigus, 
lichen, candidiasis, oral gonorrhea, and other STDs.[7‑9]

We present this case because of the rare presentation of 
localized oral lesions of secondary syphilis for 15 days with 
the absence of skin lesions. There are only a few reports of 
secondary syphilis presenting with only isolated oral lesions. 
Moreover, we emphasize the atypical oral involvement.

Presence of atypical oral ulcerations should raise the needle 
of suspicion toward underlying STDs especially in high‑risk 
group individuals. The diagnosis of syphilis may involve 
VDRL, dark field microscopy of skin lesions/mucosal lesions 
and non‑treponemal Rapid Plasma Reagin (RPR) test as 
screening tests and confirmation with a treponemal‑specific 
test Flourescent Treponemal Antibody Absorbed Assay (FTA‑
ABS) and TPHA.[10] Parenterally administered penicillin G is 
considered as the first‑line therapy for all stages of syphilis. 
Alternative regimens for nonpregnant patients with no 
evidence of central nervous system involvement include 
Doxycycline, Tetracycline, Ceftriaxone, and azithromycin.[11] 

CONCLUSION

Establishing a diagnosis of syphilis, whatever the stage of the 

disease, can be difficult because syphilis is a great mimic in 
clinical morphology and histology. Many patients infected 
with venereal diseases have oral manifestations, but very 
few dentists and physicians have the proper experience to 
diagnose syphilis or other STDs from oral lesions. Atypical 
oral lesions in high‑risk group people should raise suspicion 
toward infectious transmissible diseases. Early diagnosis of 
such cases reduces the morbidity and also prevents further 
transmission of the disease. In recent years, the secondary 
syphilitic lesions found in oral cavity have been noted as 
often atypical due to inadequate treatment as a result of 
antibiotic therapy for unrelated infections and increasing 
trend of association of syphilis with HIV infection. Attention 
should be paid to all suspicious lesions and stress on the 
seriousness of these illnesses to prevent pandemic of STDs 
by early diagnosis, education and referral.

ACKNOWLEDGEMENT

We are grateful to Department of Oral Diagnosis, Medicine and 
Radiology, K.M Shah Dental College and Hospital and Department 
of Skin And Veneral Diseases Dheeraj general hospital of 
Sumandeep university Vadodara, Gujarat for their co‑operation. 

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How to cite this article: Singh PV, Patil R. Atypical oral manifestations in 
secondary syphilis. Indian J Dent Res 2013;24:142-4.
Source of Support: Nil, Conflict of Interest: None declared.

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