The great medical imitator: a case of syphilitic osteitis in the setting of HIV infection
Janine M. Trevillyan A D , Kenneth S. Yap B and Jennifer Hoy A C
+ Author Affiliations
- Author Affiliations
A Infectious Diseases Unit, The Alfred Hospital, Melbourne, Vic. 3000, Australia.
B Department of Nuclear Medicine, The Alfred Hospital, Melbourne, Vic. 3000, Australia.
C Department of Infectious Diseases, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Vic. 3000, Australia.
D Corresponding author. Email: j.trevillyan@alfred.org.au
Sexual Health 10(3) 275-278 https://doi.org/10.1071/SH12187
Submitted: 31 October 2012 Accepted: 18 December 2012 Published: 5 April 2013
Abstract
A 44-year-old man with well-controlled HIV presented with low-grade fever, pharyngitis, frontal headache, abdominal and shin pain, and abnormal liver function tests 8 weeks after switching from zidovudine to abacavir (while continuing nevirapine and lamivudine). An abacavir reaction was the working diagnosis and thus his antiretroviral regimen was returned to the previously tolerated combination and he received 10 days of oral penicillin (500 mg twice daily) for presumptive tonsillitis with significant improvement. A whole-body bone scan demonstrated multiple foci of increased patchy osteoblastic activity of the long bones and skull. Six months later during routine screening, a syphilis rapid plasma reagin (RPR) titre of 128 was detected. Retrospective testing on stored samples demonstrated a first positive RPR at the time of symptomatic presentation. He received three injections of 1.8 g benzathine penicillin on a weekly basis with a subsequent decrease in RPR titre and normalisation of the bone scan. Although syphilitic osteitis is rare, this case re-emphasises the importance of considering syphilis when HIV-infected patients present with unusual symptoms. The use of bone scan in this setting and treatment options are discussed.
Additional keywords: bone scan, case report, rapid plasma reagin titre, symptoms, syphilis, Treponema pallidum.
References
[1] Department of Health (DoH). Surveillance of notifiable infectious diseases in Victoria 2009. Sexually transmissable infections. : DoH; 2012. Available online at: http://docs.health.vic.gov.au/docs/doc/E789DA963A3642D4CA2579CD007CA8B5/$FILE/Annual%20report%202009%20STIs.pdf [verified September 2012].[2] Angus J, Langan SM, Stanway A, Leach IH, Littlewood SM, English JS. The many faces of secondary syphilis: a re-emergence of an old disease. Clin Exp Dermatol 2006; 31 741–5.
| The many faces of secondary syphilis: a re-emergence of an old disease.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28vnslKhtg%3D%3D&md5=f00959c04e3a2568d19c495725e60811CAS | 16901332PubMed |
[3] Cohen DE, Mayer K. Genital Ulcer Disease. In Klausner JD, Hook EW, editors. Current diagnosis and treatment of sexually transmitted diseases. New York: McGraw-Hill Medical; 2007. pp. 19–26.
[4] Gayet-Ageron A, Lautenschlager S, Ninet B, Perneger TV, Combescure C. Sensitivity, specificity and likelihood ratios of PCR in the diagnosis of syphilis: a systematic review and meta-analysis. Sex Transm Infect 2012;
| Sensitivity, specificity and likelihood ratios of PCR in the diagnosis of syphilis: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar | 23024223PubMed |
[5] Cole MJ, Perry KR, Parry JV. Comparative evaluation of 15 serological assays for the detection of syphilis infection. Eur J Clin Microbiol Infect Dis 2007; 26 705–13.
| Comparative evaluation of 15 serological assays for the detection of syphilis infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2srhvVWnsg%3D%3D&md5=57a70cef15b951188113d5b8f4982d2fCAS | 17647033PubMed |
[6] Mindel A, Tovey SJ, Timmins DJ, Williams P. Primary and secondary syphilis, 20 years’ experience. 2. Clinical features. Genitourin Med 1989; 65 1–3.
| 1:STN:280:DyaL1M7lsVCntQ%3D%3D&md5=ecb91d27aaac8fb9ab2f7419d3b9cfbfCAS | 2921046PubMed |
[7] Coyne K, Browne R, Anagnostopoulos C, Nwokolo N. Syphilitic periostitis in a newly diagnosed HIV-positive man. Int J STD AIDS 2006; 17 421–3.
| Syphilitic periostitis in a newly diagnosed HIV-positive man.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28zgslKqug%3D%3D&md5=918ff2761b7e3d366ff42d876e1867eaCAS | 16734969PubMed |
[8] Etienne M, Bencteux P, Gueit I, Abboud P, Caron F. Deja vu in the catacombs: skull syphilitic osteitis. Lancet Infect Dis 2008; 8 455
| Deja vu in the catacombs: skull syphilitic osteitis.Crossref | GoogleScholarGoogle Scholar | 18582838PubMed |
[9] 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; 21 229–33.
| Destructive osteomyelitis associated with early secondary syphilis in an HIV-positive patient diagnosed by Treponema pallidum DNA polymerase chain reaction.Crossref | GoogleScholarGoogle Scholar | 17461716PubMed |
[10] Thompson RG, Preston RH. Lesions of the skull in secondary syphilis. Am J Syph Gonorrhea Vener Dis 1952; 36 332–41.
| 1:STN:280:DyaG38%2FmtlOrtQ%3D%3D&md5=07af2bb37b86455275c543b58fc75585CAS | 14933677PubMed |
[11] Lynn WA, Lightman S. Syphilis and HIV: a dangerous combination. Lancet Infect Dis 2004; 4 456–66.
| Syphilis and HIV: a dangerous combination.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2czhvFGhtg%3D%3D&md5=0e6a7198b3a6b6fd9c1aa7787e8b3d15CAS | 15219556PubMed |
[12] González-López JJ, Guerrero ML, Lujan R, Tostado SF, de Gorgolas M, Requena L. Factors determining serologic response to treatment in patients with syphilis. Clin Infect Dis 2009; 49 1505–11.
| Factors determining serologic response to treatment in patients with syphilis.Crossref | GoogleScholarGoogle Scholar | 19842977PubMed |
[13] Ghanem KG, Moore RD, Rompalo AM, Erbelding EJ, Zenilman JM, Gebo KA. Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients. Clin Infect Dis 2008; 47 258–65.
| Antiretroviral therapy is associated with reduced serologic failure rates for syphilis among HIV-infected patients.Crossref | GoogleScholarGoogle Scholar | 18532887PubMed |
[14] Knaute DF, Graf N, Lautenschlager S, Weber R, Bosshard PP. Serological response to treatment of syphilis according to disease stage and HIV status. Clin Infect Dis 2012; 55 1615–22.
| Serological response to treatment of syphilis according to disease stage and HIV status.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC38XhslKrsbnK&md5=25ed71431420f74d808d17f60278ea64CAS | 22955437PubMed |
[15] Ehrlich R, Kricun ME. Radiographic findings in early acquired syphilis: case report and cirtical review. AJR Am J Roentgenol 1976; 127 789–92.
| 1:STN:280:DyaE2s%2FhvFKrtw%3D%3D&md5=a52956f7d0f92a95ecd1767c3f28fa8cCAS | 973665PubMed |
[16] Rademacher SE, Radolf JD. Prominent osseous and unusual dermatologic manifestations of early syphilis in two patients with discordant serological statuses for human immunodeficiency virus infection. Clin Infect Dis 1996; 23 462–7.
| Prominent osseous and unusual dermatologic manifestations of early syphilis in two patients with discordant serological statuses for human immunodeficiency virus infection.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s%2FjsVWjug%3D%3D&md5=20e09e646cb1a2892970c870a6ea07c9CAS | 8879765PubMed |
[17] Keat A. Sexually transmitted arthritis syndromes. Med Clin North Am 1990; 74 1617–31.
| 1:STN:280:DyaK3M%2FmtFGguw%3D%3D&md5=c7482c2b07e7dced9e0ca49fc737a2a4CAS | 2246956PubMed |
[18] Thakore K, Viroslav A, Vansant J. Role of bone scintigraphy in the detection of periostitis in secondary syphilis. Clin Nucl Med 1994; 19 536–41.
| Role of bone scintigraphy in the detection of periostitis in secondary syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2czktVynsQ%3D%3D&md5=1af071158823a160af42d7ac7f732c3bCAS | 8062476PubMed |
[19] Hansen K, Hvid-Jacobsen K, Lindewald H, Sorensen PS, Weismann K. Bone lesions in early syphilis detected by bone scintigraphy. Br J Vener Dis 1984; 60 265–8.
| 1:STN:280:DyaL2c3lvVCntg%3D%3D&md5=0d5ed5b63133432f31dfad0a02da7676CAS | 6234967PubMed |
[20] Veerapen K, Bruckner FE, Halsey JP, Davidson F, Saeed A. Periostitis in secondary syphilis: a place for bone scintigraphy. J R Soc Med 1985; 78 721–4.
| 1:STN:280:DyaL28%2FhtFaqug%3D%3D&md5=5f16265c3729a18dc110a576b0fef4a5CAS | 4045902PubMed |
[21] Huang I, Leach JL, Fichtenbaum CJ, Narayan RK. Osteomyelitis of the skull in early-acquired syphilis: evaluation by MR imaging and CT. AJNR Am J Neuroradiol 2007; 28 307–8.
| 1:STN:280:DC%2BD2s%2FpvVSqsw%3D%3D&md5=f44157f30a21eb1e50a31ea79bf145d5CAS | 17297001PubMed |
[22] Naraghi AM, Salonen DC, Bloom JA, Becker EJ. Magnetic resonance imaging features of osseous manifestations of early acquired syphilis. Skeletal Radiol 2010; 39 305–9.
| Magnetic resonance imaging features of osseous manifestations of early acquired syphilis.Crossref | GoogleScholarGoogle Scholar | 19795120PubMed |
[23] Dismukes WE, Delgado DG, Mallernee SV, Myers TC. Destructive bone disease in early syphilis. JAMA 1976; 236 2646–8.
| Destructive bone disease in early syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaE2s%2FlsVWisQ%3D%3D&md5=46974cf5a826aaf6d12e5e88d952f120CAS | 1036540PubMed |
[24] Gurland IA, Korn L, Edelman L, Wallach F. An unusual manifestation of acquired syphilis. Clin Infect Dis 2001; 32 667–9.
| An unusual manifestation of acquired syphilis.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3MvkslWmuw%3D%3D&md5=ab5ebaf602bc766f58a1dcbbfe10319eCAS | 11181137PubMed |
[25] Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14. Melbourne: Therapeutic Guidelines Limited; 2010.
