International Journal of Infectious Diseases 35 (2015) 40–42

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International Journal of Infectious Diseases

Medical Imagery

Oral Manifestations of Secondary Syphilis

A R T I C L E I N F O S U M M A R Y

Article history: Known as ‘‘the great imitator,’’ secondary syphilis may clinically manifest itself in myriad ways,
Received 10 February 2015 involving different organs including the oral mucosa, and mimicking, both clinically and histologically,
Received in revised form 6 April 2015 several diseases, thereby making diagnosis a challenge for clinicians. We highlight the clinical aspects of
Accepted 10 April 2015
oral manifestation in 7 patients with secondary syphilis. Clinicians should consider secondary syphilis in
Corresponding Editor: Eskild Petersen, the differential diagnosis of ulcerative and/or white oral lesions.
Aarhus, Denmark
ß 2015 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
Keywords: nc-nd/4.0/).
secondary syphilis
oral cavity
mucous patches

Figure 1. Clinical features of the ‘‘mucous patches’’ form. Slightly and oval elevated plaques, sometimes ulcerate, covered with a white or gray pseudomembrane in the soft
palate and labial mucosa.

http://dx.doi.org/10.1016/j.ijid.2015.04.007
1201-9712/ß 2015 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 Medical Imagery / International Journal of Infectious Diseases 35 (2015) 40–42 41

Figure 2. Clinical features of the ‘‘mucous patches’’ form. Serpiginous lesions affecting oral mucosa, described as snail track ulcers.

Figure 3. Clinical features of the ‘‘leukoplakia-like’’ form. A well delimited raised surface that was a corrugated, nonhomogeneous white plaque in oral mucosa of two distinct
patients.

1. Description Several clinical forms are described for the secondary syphilis
affecting oral mucosa, among which the most common is called
Syphilis is an acute and chronic sexually transmitted disease which ‘‘mucous patches’’ with two subtypes: slightly elevated-type
is caused by an anaerobic tightly coiled helical bacterial species, plaques and, occasionally, ulcerated, which are usually oval and
Treponema pallidum.1–4 On the basis of its activity and infectivity covered with a gray or white pseudomembrane; or multiple mucous
phase, acquired syphilis can be classified into four stages: primary, patches that may coalesce to give rise to serpiginous lesions,
secondary, latent, and tertiary.3,4 Oral lesions are principally described as snail track ulcers. White plaques with verrucous aspect,
associated with secondary syphilis, although all stages can give rise so-called ‘‘leukoplakia like’’ are also described as another frequent
to oral manifestations.1,2 This wide array of manifestations has given form of disease. However, some cases can manifest atypically, and
syphilis the reputation as the ‘‘great imitator’’. the diagnosis can be delayed or even missed.1,2

Table 1
Description of clinical data of patients with secondary syphilis.

Patient Age Sex Medical history Site Type of manifestation Serological test PB treatment

1 19 Male Skin lesions Hard palate, inferior lip and Mucous Patches VDRL+ 1/8 / FTA-ABS + 2,400,000 UI, single dose
tongue
2 40 Female No Inferior and superior lip Mucous Patches VDRL+ 1/32 / FTA-ABS + 2,400,000 UI, single dose
3 25 Female Genital lesion Buccal mucosa and tongue Mucous Patches VDRL - / FTA-ABS + 2,400,000 UI, single dose
4 32 Male No Buccal mucosa and superior lip Mucous Patches VDRL+ 1/128 / FTA-ABS + 1,200,000 UI 4 times,
weekly interval
5 9 Female Skin lesions Inferior lip and tongue Mucous Patches VDRL - / FTA-ABS + 2,400,000 UI, single dose
6 29 Male Genital lesion Buccal mucosa and tongue ‘‘Leukoplakia-like’’ plaque VDRL+ 1/64 / FTA-ABS + 2,400,000 UI, single dose
7 21 Female Genital lesion Hard palate and inferior lip ‘‘Leukoplakia-like’’ plaque VDRL+ 1/32 / FTA-ABS + 1,200,000 UI 4 times,
weekly interval

VDRL, Venereal Disease Research Laboratory; FTA-Abs, fluorescent treponemal antibody absorption; PB, penicillin benzathin.
42 Medical Imagery / International Journal of Infectious Diseases 35 (2015) 40–42

Table 1 summarizes the clinical profiles, serologic results, 3. Husein-Elahmed H, Ruiz-Carrascosa JC. Secondary syphilis presenting as rash
and annular hyperkeratotic lesions. Int J Infect Dis 2011 Mar;15(3):e220. http://
and treatment modalities of 7 patients with secondary syphilis dx.doi.org/10.1016/j.ijid.2010.12.006.
(Figs. 1–3). The patients presented here were referred for serologic 4. Zoni AC, González MA, Sjögren HW. Syphilis in the most at-risk populations in
testing, which revealed a positive result for syphilis (Venereal Latin America and the Caribbean: a systematic review. Int J Infect Dis
2013 Feb;17(2):e84–92. http://dx.doi.org/10.1016/j.ijid.2012.07.021.
Disease Research Laboratory [VDRL] positive, Fluorescent Trepo-
nemal Antibody [FTA-Abs] positive, Treponema pallidum IgM
positive). Therapy with benzathine-penicillin, administered intra-
muscularly led to complete remission of oral lesions and other Luiz Fernando Barbosa de Pauloa,b,*
symptoms in all patients. João Paulo Silva Servatoa
Medical practitioners should consider secondary syphilis in the Maiolino Thomaz Fonseca Oliveirab
differential diagnosis of white and ulcerative oral lesions, Antonio Francisco Durighetto Jra
particularly in at-risk groups, and ask questions regarding the Darceny Zanetta-Barbosab
development of lesions after sexual activity.1,2 a
Program of Specific Care of Oral Diseases, Stomatology Diagnosis
Conflict of interest: No conflict of interest to declare. Unit, HC, Federal University of Uberlândia, MG, Brazil
b
Department of Oral and Maxillofacial Surgery, Federal University of
References Uberlândia, MG, Brazil
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unsuspected oral lesions of syphilis. Int J Oral Maxillofac Surg *Corresponding author. Program of Specific Care of Oral
2014 Dec;43(12):1436–40. http://dx.doi.org/10.1016/j.ijom.2014.09.014. Diseases - PROCEDE, Stomatology Diagnosis Unit; Federal
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