Article Text

Case report
Syphilitic periostitis of the skull and ribs in a HIV positive patient
  1. Michael Samarkos1,
  2. Charis Giannopoulou2,
  3. Eleni Karantoni1,
  4. Vassileios Papastamopoulos3,
  5. Ioannis Baraboutis3,
  6. Athanassios Skoutelis1,3
  1. 15th Department of Internal Medicine, Evagelismos Hospital, Athens, Greece
  2. 2Nuclear Medicine Department, Evagelismos Hospital, Athens, Greece
  3. 3Infectious diseases Unit, Evagelismos Hospital, Athens, Greece
  1. Correspondence to Michael Samarkos, 5th Department of Internal Medicine, Evagelismos Hospital, 45 Ipsilantou street, Athens 10676, Greece; msamarkos{at}gmail.com

Abstract

We report the case of a HIV and syphilis co-infected patient who presented with headache and rash and was found to have syphilitic periostitis. Our case illustrates a rare manifestation of early syphilis and presents the diagnostic dilemmas that can arise in HIV and syphilis co-infected patients.

  • HIV infections
  • AIDS
  • syphilis
  • periostitis
  • CNS
  • HIV

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Case report

A 25-year-old Caucasian man presented to the emergency department with a temporal-frontal bilateral headache lasting for a week. His past medical history was unremarkable and he was not taking any medication. The patient was alert, oriented, with normal level of consciousness and vital signs. There was no fever, vomiting or focal neurological signs. Physical examination revealed a few maculopapular lesions on the soles. Cerebrospinal fluid (CSF) examination at the emergency department revealed mild pleocytosis (30 cells/μl, predominantly lymphocytes), increased protein (100 mg/dl, normal range<50 mg/dl) and normal glucose. Gram and acid-fast stains showed no bacteria and latex tests for Cryptococcus sp. and Streptococcus pneumoniae were also negative. He was admitted with a working diagnosis of viral meningitis. Complete blood count and serum chemistries were within normal limits. Further testing revealed that the patient was HIV positive with a CD4 count of 340/μl and a viral load of 44500 copies/ml. Serum non-treponemal and treponemal tests were positive (Venereal Disease Research Laboratory (VDRL) =1/8; fluorescent treponemal antibody-absorption (FTA-ABS) =+++), while CSF VDRL was negative. CSF PCR for Coxsakie and Echo viruses was negative. Head MRI was unremarkable.

Six months earlier the patient had tested negative for HIV. He could not recall any symptoms or signs suggestive of acute HIV infection or any genital or mouth ulcers in the past few months. However, he reported a high risk sexual contact approximately 6 weeks before the headache started.

One day after his admission the patient complained of pain on the left hemithorax. On examination there was only tenderness on palpation on the anterior part of the 8th rib. Chest radiograph was normal. However, bone scan showed increased 99mTc-MDP uptake, suggestive of periostitis, in the skull and the anterolateral arche of the 7th, 8th and 10th left ribs (figure 1). Skull plain films were normal. On further questioning the patient reported that he felt that the headache was getting worst by pressure on the skull bones.

Figure 1

99mTc Bone scan showing increased uptake in the skull (panels A and B) and ribs (panel C).

We diagnosed secondary syphilis with cutaneous and bone involvement based on the rash, the positive serology and the bone scan findings. Because of the positive serology and the abnormal CSF, neurosyphilis could not be ruled out; therefore, intravenous penicillin G, 18 million units daily, was started. Five days after initiation of treatment the patient was asymptomatic and he started antiretroviral treatment with abacavir, lamivudine, lopinavir and ritonavir. A follow-up bone scan 3 months after treatment revealed resolution of the rib lesions but persistently abnormal uptake in the skull (see supplementary figure online).

Discussion

Skeletal involvement is unusual in early acquired syphilis. It can present as periostitis, arthritis, osteitis or osteomyelitis. Syphilitic periostitis was originally described in 1887 by J Hutchinson as quoted by Roy et al.1 Periostitis in particular is rarely reported. It was reported in only 2 out of 854 patients in an earlier study.2 Literature on syphilitic periostitis is limited to case reports.3 4

During early syphilis, spirochaetes can haematogenously spread to the periosteoum, Haversian canals and medulary spaces resulting in periostitis, osteitis or osteomyelitis.5

Long bones in both arms and legs are usually involved, while skull periostitis is less frequent. Clinically, there is tenderness over the involved bones, which is sharply localised and may be accompanied by local pitting oedema.1 Pain is aggravated during the night6 and on exposure to heat.1

In most cases of syphilitic periostitis radiological changes are minimal. When radiologically detectable, periosteal reaction is usually laminated or solid but can be perpendicular suggesting osteosarcoma. In the skull, soft tissue swelling and wavy periosteal reaction can be found.5 In our patient, both plain radiographs as well as MRI of the head were normal. Bone scintigraphy is more sensitive than radiography in early detection of secondary syphilis skeletal lesions, such as syphilitic periostitis, and can be useful in the determination of disease extent, in biopsy guiding and in patients' follow-up.7 In our patient, the follow-up scan showed that although rib lesions had cleared skull lesions persisted. A possible explanation for that is that skull lesions were more severe and they would need more time to resolve. Although MRI in our patient did not reveal bone changes, there are reports that MRI can aid to the diagnosis of syphilitic periostitis.8

The diagnosis of syphilitic periostitis can be difficult if other manifestations of early syphilis, such as genital ulcers and rash, go unnoticed. One of the reasons why syphilitic bone involvement of the skull (eg, periostitis) can go undiagnosed is because headaches may be attributed to meningeal involvement.9 In our patient, the presence of skull syphilitic periostitis and HIV seropositivity created a diagnostic dilemma since headache could be attributed to any of syphilitic periostitis of the skull, syphilitic meningitis or HIV-associated aseptic meningitis.10

As the incidence of syphilis is increasing, especially among HIV positive patients, it is expected that some patients will present with unusual manifestations.11 Therefore, physicians should have a high index of suspicion in order to diagnose early these patients.

Key messages

  • Skeletal involvement is rare in early acquired syphilis and it can present as periostitis, arthritis, osteitis or osteomyelitis.

  • Syphilitic periostitis usually involves long bones but it can involve the skull as well. There is pain and localised tenderness over the affected bones.

  • Syphilitic periostitis can cause diagnostic dilemmas or be confused with other manifestations of syphilis—eg, skull periostitis with syphilitic meningitis.

  • As the incidence of syphilis is increasing, especially among HIV positive patients, physicians should have a high index of suspicion to recognise its protean manifestations.

References

Supplementary materials

Footnotes

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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