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Scientific letter
Secondary syphilis mimicking systemic rheumatic disease: Report of 2 cases
Sífilis secundaria simulando una enfermedad reumatológica sistémica: reporte de 2 casos
Daniel Erlij Opazo
Sección de Reumatología, Servicio de Medicina Hospital del Salvador, Sede Oriente, Universidad de Chile, Santiago, Chile
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Syphilis&#44; an infectious disease caused by <span class="elsevierStyleItalic">Treponema pallidum</span>&#44; has been described as the &#8220;great imitator&#8221; in medicine&#44; especially in its secondary stage&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Far from being a topic restricted to the pre-antimicrobial era&#44; this disease is now a public health problem&#44; with 7&#46;1 million new cases per year in adults worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This means it has to be considered as part of the differential diagnosis for numerous clinical manifestations&#44; many of which are shared with systemic rheumatological diseases such as lupus and Still&#8217;s disease&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 42-year-old woman&#44; with a sister with rheumatoid arthritis&#44; who consulted for two months of polyarthralgia of small and large joints&#44; associated with odynophagia&#44; episodes of unquantified febrile sensation and maculopapular rash on the chest&#44; abdomen and upper limbs&#44; without palmoplantar involvement&#44; pain or pruritus&#46; Physical examination revealed only the described rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Full blood count showed white blood cells of 6900&#47;mm<span class="elsevierStyleSup">3</span>&#44; lymphocyte count of 1104&#47;mm<span class="elsevierStyleSup">3</span> and an erythrocyte sedimentation rate of 63&#8239;mm&#47;h&#46; The rest of the general examinations were normal&#46; Anti-nucleocytoplasmic antibodies &#40;ANA&#41; were positive &#40;1&#47;80 with homogeneous pattern&#41;&#44; with negative anti-ENA&#44; anti-DNA&#44; rheumatoid factor and anti-neutrophil cytoplasm&#44; as well as normal complements C3 and C4&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Despite denying risk factors&#44; a VDRL &#40;Venereal disease research laboratory&#41; test was requested and was positive &#40;1&#47;64&#41;&#44; as was the MHA-TP &#40;microhaemagglutination assay for <span class="elsevierStyleItalic">T&#46; pallidum</span> antibodies&#41;&#46; HIV&#44; HBV and HCV were negative&#46; The patient was given benzathine penicillin &#40;2&#46;4 million IU&#41; as a single dose&#44; with excellent clinical response&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another case was that of a 63-year-old male&#44; with a sister with lupus nephropathy&#44; who consulted with a two-month history of papular rash on his trunk and upper limbs&#44; with involvement of the palms&#44; associated with episodes of unquantified febrile sensation&#46; He also reported polyarthralgia of small and large joints&#44; mild oedema of the lower limbs and odynophagia&#46; Physical examination revealed rash &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#44; mild soft oedema on both legs&#44; painless cervical lymphadenopathy and two mouth ulcers&#44; one on the hard palate and the other on the right lateral border of the tongue&#46; Full blood count showed leucocyte count 6200&#47;mm<span class="elsevierStyleSup">3</span>&#44; lymphocyte count 1099&#47;mm<span class="elsevierStyleSup">3</span> and erythrocyte sedimentation rate 37&#8239;mm&#47;h&#46; The rest of the general examinations were normal&#46; Positive ANA test with titre 1&#58;640 with speckled pattern&#44; with negative anti-ENA&#44; anti-dsDNA&#44; rheumatoid factor and anti-neutrophil cytoplasm&#44; as well as normal complements C3 and C4&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite denying risky sexual behaviour&#44; a VDRL test was requested and was positive &#40;1&#47;64&#41;&#44; as was MHA-TP&#46; HIV&#44; HBV and HCV were negative&#46; The patient was given benzathine penicillin &#40;2&#46;4 million IU&#41; as a single dose&#44; with excellent clinical response&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">One to two months after the primary syphilitic lesion&#44; which may go unnoticed&#44; secondary manifestations arise due to haematogenous spread of <span class="elsevierStyleItalic">T&#46; pallidum</span>&#46; These can include symptoms such as fever&#44; rash&#44; odynophagia&#44; lymphadenopathy&#44; polyarthralgia or arthritis&#44; mucosal lesions&#44; alopecia&#44; hepatitis and renal involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The rash&#44; present in more than 80&#37; of patients&#44; is characteristically non-pruritic and involves the whole body&#44; including palms and soles&#44; which is considered key for clinical suspicion&#46; It is usually maculopapular&#44; symmetrical and sometimes even scaling&#44; similar to psoriatic plaques&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The diagnosis of secondary syphilis is confirmed by a positive VDRL and treponemal tests&#44; such as the MHA-TP&#46; Regarding treatment&#44; there is consensus on the single-dose schedule with benzathine penicillin 2&#44;400&#44;000 IU&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The cases described have a number of similarities&#46; They both consulted rheumatology in the first instance and had a family history of autoimmune diseases&#46; The symptoms were very similar&#44; as was having a lymphocyte count at the lower limit&#44; an aspect not consistent with the literature&#44; which generally describes lymphocytosis&#44; except when it occurs in patients with HIV&#44; in whom lymphopenia predominates&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Both patients had a positive ANA&#44; which can occur in infectious diseases&#44; especially tuberculosis and syphilis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The fact that 24&#37; of lupus patients can have false-positive VDRL can make the differential diagnosis even more difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In conclusion&#44; both conditions had clinical features of systemic autoimmune diseases&#44; such as lupus and Still&#39;s disease&#44; especially polyarthralgia and rash associated with fever and mouth ulcers&#46; Secondary syphilis should therefore always be considered in the differential diagnosis of diseases that appear to be of rheumatic aetiology&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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