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Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 5  |  Page : 670-673
Conventional systemic treatments associated with therapeutic sites of local lesions of secondary syphilis in the oral cavity in patients with AIDS


Center for Studies and Consultations in Special Patients (CEAP) and Graduate Studies and Research/Dental, Universidade Paulista, Brazil

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Date of Submission15-Jun-2011
Date of Decision19-Oct-2011
Date of Acceptance03-May-2012
Date of Web Publication19-Feb-2013
 

   Abstract 

Patients with HIV infection may develop common diseases with atypical clinical features. HIV infection can change the classic clinical course of syphilis and increase the incidence of malignant syphilis. Malignant syphilis is a rare subtype of secondary syphilis that presents special clinical and histological features and has been associated with several processes characterized by variable degrees of immunosuppression. It is necessary to consider the possibility of this entity in the differential diagnoses in HIV-infected patients with cutaneous lesions. The dental surgeon (or oral surgeon) is vital to the medical team for promoting the health and improving the quality of life of syphilis patients. A patient with HIV infection was referred to us for complaints of a white patch on the tongue, stinging and burning sensation on the tongue, loss of taste, and dryness of the mouth. On clinical examination, the patient was found to have a tabetic gait (the Prussian soldier gait) associated with Charcot arthropathy. We also identified bilateral lesions with ulceration and exposure of the tissue that were tender, characterized by discrete necrosis. The treatment that was initiated at that time involved cleaning the area with gauze to remove all the white patches, followed by rinsing with bicarbonate in water (one teaspoon of baking soda dissolved in half a glass of water) four times a day. Additionally, fluconazole (100 mg/day for 7 days) was prescribed. We diagnosed secondary malignant syphilis of approximately 5 days duration. As an adjunctive therapy, we performed low-intensity laser treatment using a GaAsAl (gallium-aluminum arsenide) laser at 790 nm. With this treatment there was progressive resolution of the lesions.

Keywords: Acquired syphilis, congenital, HIV, low-output lasers, malignant syphilis, oral manifestations, sexually transmitted diseases, syphilis, Treponema pallidum

How to cite this article:
Giovani EM, de Paula Neto ER, Vieira BC, de Andrade DM. Conventional systemic treatments associated with therapeutic sites of local lesions of secondary syphilis in the oral cavity in patients with AIDS. Indian J Dent Res 2012;23:670-3

How to cite this URL:
Giovani EM, de Paula Neto ER, Vieira BC, de Andrade DM. Conventional systemic treatments associated with therapeutic sites of local lesions of secondary syphilis in the oral cavity in patients with AIDS. Indian J Dent Res [serial online] 2012 [cited 2020 Aug 5];23:670-3. Available from: http://www.ijdr.in/text.asp?2012/23/5/670/107390
Syphilis is a chronic infectious disease that is mostly transmitted by exual contact. Vertical transmission from mother to child during pregnancy is also possible. The disease is characterized by periods of activity and latency, widespread systemic involvement, and progression to severe complications. It has three distinct stages. Primary syphilis is characterized by chancres, secondary syphilis is characterized by syphilitic rose spots, and tertiary syphilis is characterized by gummas. Syphilis affects practically all organs and systems and, despite the availability of effective low-cost treatments, it continues to be a major public health concern in developed and undeveloped countries alike to this day. It has been known since the fifteenth century, and its etiological agent, Treponema pallidum, was first described more than 100 years ago. Since 1943, it has been treated efficaciously with penicillin and this led many to think that the disease could be controlled, resulting in diminished interest in its study and elimination. Changes in sexual behavior over the past four decades have caused the number of syphilis cases to rise again.

With the advent of acquired immunodeficiency syndrome (AIDS), there has been a resurgence of sexually transmitted diseases (STDs). The role of syphilis as a facilitating factor in HIV transmission aroused new interest in the need for control strategies for syphilis. There has been a recrudescence of syphilis in groups engaging in risk behaviors, such as men who have sex with men (MSM) and sex workers. The use of laboratory tests for accurate diagnosis, proper treatment of the patient and his/her partner, promotion of condom use, and dissemination of information to the public are the measures adopted for control of syphilis.

The dental surgeon (or oral surgeon) is vital to the medical team for promoting health and improving quality of life of syphilis patients. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]


   Case History Top


A male patient (18 years old, single, Caucasian, MSM, sex worker, intravenous drug user, and user of marijuana and crack cocaine) was referred by a Customer Service Specialist in the Sexually Transmitted Diseases STD/AIDS Program of São Paulo, to the Center for the Study and Treatment of Special Patients (CEAPE UNIP), São Paulo University, Indianapolis Campus, São Paulo, Brazil, for complaints of a 'white patch on the tongue,' stinging and burning sensation on the tongue, loss of taste, and dryness of the mouth. The accompanying medical report and patient anamnesis revealed that he was HIV positive (rapid test performed by the rapid HIV ½ Cheek immunoassay method), hepatitis C, and syphilis (VDRL 1: 64 and TPHA reagent). The CD4 T-lymphocyte level was 75 cells/mm 3 and the viral load was 85000 copies/ml. The patient had progressive and almost total loss of visual acuity, accompanied with auditory neuritis and iridocyclitis. He had small pupils that were unequal, irregular, and not reactive to light. The patient also had alopecia, adynamia, general prostration, malaise, asthenia, anorexia, fever, headache, arthralgia, myalgia, sore throat, hoarseness, severe itching throughout the body, numbness in the extremities, suicidal ideation, loss of appetite, and sore throat. In addition, he complained of uncontrolled defecation and urination, and a decrease in libido.

On clinical examination, the patient was found to have a tabetic gait (the Prussian soldier gait) associated with Charcot arthropathy. The Romberg sign was positive even though there is sometimes a tendency to drop one side now on the other side without a side predominance. The index was carried out of the nose with eyes closed and did not correspond to the conventional placement of the missing finger on his nose. There was palpable lymphadenopathy involving several nodes in all cervical chains; the nodes were mildly painful and roughly 1 cm in diameter. The patient had fairly representative hepatosplenomegaly. He had crusting skin lesions and a maculopapular rash, a copper-colored erythema, and rupia that were either round with discrete flat surfaces or high and covered with fine scales that were more intense at the periphery (Biett's collarette). These syphilitic lesions, the so-called syphilitic roseola, had scaly, symmetric characteristics and affected the entire front and back of the torso, arms, legs, neck [Figure 1], and facial/oral area. They were approximately 0.5 cm in diameter throughout the length of the rash [Figure 2]. There was intense itching, especially in the plantar and palmar regions [Figure 3], where the rash was lush. This clinical picture was very typical of early malignant syphilis.
Figure 1: Scaly maculopapular skin lesions on the back of the trunk

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Figure 2: Scaly lesions on the facial region

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Figure 3: Exuberant lesions in the palmar and plantar regions

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On physical examination, intraoral erythroleukoplakia lesions were observed in the hard and soft palate, extending throughout the oropharynx [Figure 3]. Painless pseudomembranous and erythematous candidiasis was diagnosed in the tongue and oral commissures and in the corners of the mouth (angular cheilitis) [Figure 4]. We also identified bilateral lesions with ulceration and exposure of the tissue that were tender, with striking clinical features, including raised edges and a fine bed of white mucous, inside, they were characterized by discrete necrosis.
Figure 4: Erythroleukoplakia lesions in the hard palate extending across oropharynx

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The treatment that was initiated at that time involved cleaning the area with gauze to remove all the white patches, followed by rinsing with bicarbonate in water (one teaspoon of baking soda dissolved in half a glass of water) four times a day. Additionally, fluconazole (100 mg/day for 7 days) was prescribed.

We diagnosed secondary malignant syphilis of approximately 5 days duration [Figure 5]. At that time, as an adjunctive therapy, we performed low-intensity laser treatment using a GaAsAl (gallium-aluminum-arsenide) laser at 790 nm and 30 mW for a total of 2 min per point in each region, equivalent to approximately 4 J/cm 2 of energy density. This treatment has analgesic, anti-inflammatory, and anti-bacterial functions, and also promotes cell proliferation and tissue repair. This treatment was successful in relieving the symptoms. There were no adverse effects.
Figure 5: Erosive lesions with raised edges in the oral mucosa - erythroleukoplakia.

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We also evaluated salivary flow. The patient was asked to chew a sugar-free chewing gum for 5 min and spit out the saliva produced. Only 0.3 ml of saliva was collected, thus confirming the presence of severe xerostomia. The treatment prescribed by the doctor, which was administered in the hospital environment, was based on neurological symptoms and forward to the patient's immune system and potential complications of therapy itself advocated, and monitored to every moment.

Additionally, the patient was in AIDS. A lumbar puncture was done and examination of the cerebrospinal fluid showed changes in the lymphocyte count and protein levels. Based on these findings intravenous crystalline penicillin in dextrose was administered. This drug has the capacity to cross the blood-brain barrier. The recommended dose was 4000000 IU, every 4 hours (24000000 IU/day), for 10 days. By day 5, the patient showed good regression of the symptoms. He was maintained on 4800000 IU benzathine penicillin, which was injected in doses of 2 × 2400000 IU, weekly for 4 weeks. The patient was also started on highly active antiretroviral therapy (HAART): Combivir TM 12/12 hours + Efavirenz TM , one dose/night, Bactrim TM F, 1 dose/day, and azithromycin, 3 doses (500 mg)/week. The patient has been under observation in our facility for 10 months and clinical and laboratory findings have shown no evidence of relapse or reinfection.


   Discussion Top


Malignant syphilis is a rare, ulcerative variety of secondary syphilis. Synonyms for this condition found in the medical literature include syphilis maligna praecox, lues maligna, and noduloulcerative syphilis. [3]

Coinfection with syphilis is an important co-factor, modifier, and facilitator for acquiring HIV and vice versa. Syphilis in HIV-positive patients demonstrates atypical features, such as persistent and multiple lesions. It is extremely important to identify and treat these lesions because they teem with highly contagious spirochetes. [1],[2],[3],[4]

The drug of choice for syphilis is still penicillin. For oral lesions, low-power laser is a new option. This procedure exerts anti-inflammatory effects, stimulates the release of adrenal corticosteroid hormones, and contributes to a greater expression of collagen and elastic fibers during the healing process by increasing neovascularization and fibroblast proliferation and by stimulating antioxidant activity. [12],[13],[14],[15]


   Conclusion Top


  • Syphilis in HIV-positive patients can present with atypical features, such as persistent and multiple lesions in the oral cavity and genitals, which facilitates the transmission of a variety of STDs.
  • Therapeutic measures, such as removing the plaques of candidiasis with gauze, the use of bicarbonate water for promoting the balance of microflora by inhibiting the proliferation of fungi, the use of low-power GaAsAl laser treatment for reducing painful symptoms and promoting tissue repair, can play an extremely important role in relieving symptoms and improving the quality of life of the patient. They are effective, low-cost interventions that are devoid of adverse reactions.
  • This paper presents clinical and scientific knowledge necessary for the establishment of oral diagnosis and its implications in everyday practice for dentists, making it easier to promote the prevention, diagnosis, and treatment of STDs.

   Acknowledgments Top


We wish to thank the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Programa de Suporte à Pós-Graduação de Instituições de Ensino Particulares (CAPES-PROSUP) for the support given to this work.

 
   References Top

1.Rompalo AM, Joesoef MR, O'Donnell JA, Augenbraun M, Brady W, Radolf JD, et al. Syphilis and HIV Study Group. Clinical manifestations of early syphilis by HIV status and gender: Results of the syphilis and HIV study. Sex Transm Dis 2001;28:158-65.  Back to cited text no. 1
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2.Witkowski JA, Parish LC. The great imitator: Malignant syphilis with hepatitis. Clin Dermatol 2002;20:156-63.  Back to cited text no. 2
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3.Lynn WA, Lightman S. Syphilis and HIV: A dangerous combination. Lancet Infect Dis 2004;4:456-66.  Back to cited text no. 3
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4.Hall CS, Klausner JD, Bolan GA. Managing Syphilis in the HIV-infected Patient. Curr Infect Dis Rep 2004;6:72-81.  Back to cited text no. 4
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5.D'Amico R, Zalusky R. A case of lues maligna in a patient with acquired immunodeficiency syndrome (AIDS). Scand J Infect Dis 2005;37:697-700.  Back to cited text no. 5
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6.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.  Back to cited text no. 6
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7.Dylewski J, Duong M. The rash of secondary Syphilis. CMAJ 2007;176:33-5.  Back to cited text no. 7
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8.Blitshteyn S. Secondary headache in secondary syphilis. Headache 2009;49:457-60.  Back to cited text no. 8
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9.Agusti-Mejias A, García-Ruiz R, López-Davia J, Pérez-Ferriols A, Vilata-Corel JJ, Miquel VA. Sífilis secundaria nodular generalizada. Piel (Barc., Ed. Impr.). 2010.  Back to cited text no. 9
    
10.Passoni LFC, Menezes JÁ, Ribeiro SR, Sampaio ECO. Lues maligna in an HIV-infected patient. Rev Soc Bras Med Trop 2005;38:181-4.  Back to cited text no. 10
    
11.Pugliese LS, Medrado AP, Reis SRA, Andrade ZA. The influence of low-level laser therapy on biomodulation of collagen and elastic fibers. Pesqui Odontol Bras 2003;17:307-13.  Back to cited text no. 11
    
12.Albertini R, Aimbire FS, Correa FI, Ribeiro W, Cogo JC, Antunes E, et al. Effects of different protocol doses of low power gallium-aluminum-arsenate (Ga-Al-As) laser radiation (650 nm) on carrageenan induced rat paw ooedema. J Photochem Photobiol B 2004;74:101-7.  Back to cited text no. 12
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13.Antonaccio RA, Fernandes S, Andia-Merlin R, Giovani EM. Treatment of Periodontal Disease Associated to Low-potency Laser in Patients with Down Syndrome. In: The 20 th Annual Meeting on Special Care Dentistry, 2008, San Antonio: Adaptations and Inovations for treating an Increasingly Diverse Special Needs Population; 2008. p. 14-5.  Back to cited text no. 13
    
14.Pleimes M, Hartschuh W, Kutzner H, Enk AH, Hartmann M. Malignant Syphilis with Ocular Involvement and Organism-Depleted Lesions. Clin Infect Dis 2009;48:83-5.  Back to cited text no. 14
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15.De Socio GV, Simonetti S, Tomasini C, Ansidei V, Pasticci MB, Baldelli F. Malignant syphilis with ocular involvement in an HIV-infected patient. Int J STD AIDS 2011;22:298-300.  Back to cited text no. 15
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Correspondence Address:
Edson Rodrigues de Paula Neto
Center for Studies and Consultations in Special Patients (CEAP) and Graduate Studies and Research/Dental, Universidade Paulista
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.107390

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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