Challenges in Treating Secondary Syphilis Osteitis in an Immunocompromised Patient with a Penicillin Allergy: Case Report and Review of the Literature

Abstract

Syphilis is a sexually transmitted infection that remains fairly commonplace. The introduction of penicillin aided in curbing the incidence of disease; however, with the advent of the human immunodeficiency virus (HIV), syphilis is now on a resurgence with sometimes curious presentations. We present a case of a 36-year-old Caucasian gentleman with untreated HIV who complained of a skin eruption and joint pains for 6 weeks, prompting the diagnosis of secondary syphilis osteitis. Skin lesions were reminiscent of “malignant” syphilis. CD4 count was 57 cells/μL. RPR was elevated with 1 : 64 titer and positive confirmatory TP-PA. Radiography of the limbs revealed polyostotic cortical irregularities corroborated on bone scintigraphy. The patient had an unknown penicillin allergy and was unwilling to conduct a trial of penicillin-based therapy. He was subsequently treated with doxycycline 100 mg twice daily for 6 weeks and commenced antiretroviral therapy, noting dramatic improvement in both the skin lesions and joint pains. Unfortunately, he defaulted on follow-up, precluding serial RPR and bone imaging. Penicillin allergies have proven to be quite a conundrum in such patients, without much recourse for alternative therapy. Doxycycline with/without azithromycin is other options worth considering.

Osteoarticular Infections Following Open or Penetrating Trauma in Children in the Post-Community-Acquired Methicillin-resistant Staphylococcus aureus Era: The Impact of Enterobacter cloacae

“…8 In North American literature, however, the term osteitis most often refers to inflammation of bone secondary to a non-bacterial etiology 9 or syphilis. 10 For purposes of simplicity, we will refer to this entity as trauma related OAI (TROAI) to encompass infection of a bone and/or joint secondary to inoculation of microorganisms from penetrating or open trauma. Following trauma involving direct inoculation into or exposure of bone or synovium, the risk of infection is high.…”

Malignant syphilis: a new and revised definition

“…The spirochetes may enter the vasculature of the periosteum, resulting in bone involvement (Figure 5), where they may present with localized pain and swelling 45 . The skull or bones of the extremities can be affected.…”

“…As patients may also have systemic manifestations, appropriate imaging should be performed if the patient is symptomatic (Table 3). While bone lesions may be detected with radiographs, scintigraphy has been shown to be more sensitive at early detection of osseous involvement 45 . As patients may have optic involvement, any patient with malignant syphilis should have a full ophthalmologic examination.…”

“…The lesions often resolve within weeks to a few months after treatment 56,64,79 . Patients with systemic manifestations, such as liver, bone, or lung involvement, often demonstrate resolution of physical examination, laboratory, and radiographic abnormalities after appropriate antibiotic treatment 45,56,57 …”

“…The spirochetes may enter the vasculature of the periosteum, resulting in bone involvement (Figure 5), where they may present with localized pain and swelling. 45 The skull or bones of the extremities can be affected. In the majority of the time, these lesions are multifocal, with a systematic review of bone involvement in secondary syphilis revealing that of 37 patients with bone involvement, 73% had multifocal lesions.…”