Demonstration of Treponema pallidum in a cutaneous gumma by indirect immunofluorescence

Abstract

Treponema pallidum was demonstrated in a cutaneous, tertiary syphilitic lesion by indirect immunofluorescence microscopy, but not by darkfield microscopy illumination or silver stain. The numerous organisms observed by this method may help explain the histologically vigorous tissue reaction in tertiary syphilis, despite the scarcity of organisms demonstrable by other methods.

The Immunopathobiology of Syphilis: The Manifestations and Course of Syphilis Are Determined by the Level of Delayed-Type Hypersensitivity

“…In support of this is an ultrastructural study that has demonstrated severe degradation of spirochetes in late lesions (257), and the infrequent detection of treponemal antigens or DNA in tertiary syphilis (41, 53, 56). This example of a gumma with abundant positive granular (destroyed treponemal cell wall) supports the contention that non-viable treponemal antigen is promoting the immune response.…”

“…Therefore, the testing of syphilis in tissue and other bodily fluids offers another important method to diagnose cases of syphilis that escaped screening, or in cases where syphilis was not considered in the clinical differential diagnosis. Silver staining (Levaditi, Warthin-Starry, Steiner, or Dieterle stains), direct immunofluorescence, and immunohistochemistry are methods that can directly detect spirochetes in formalin fixed, paraffin embedded tissue, particularly when organisms are numerous, as is the case in chancres and early lesions of secondary syphilis (28, 34–53). As syphilis progresses to latent and tertiary stages, spirochetes become scarce, so these methods fail, due to the detection limit being exceeded.…”

“…Tertiary skin lesions can be divided into two basic types: nodules and persistent gummatous ulcers. These two basic manifestations can yield diverse clinical morphologies that again can mimic other diseases: erythemato-violaceous annular scaling plaques similar to sarcoidosis and psoriasis, granuloma annulare-like lesions, juxta-articular nodules, pressure ulcers, pseudochancre redux (penile ulcer), discoid lupus erythematosus-like lesions, necrobiosis-like lesions, and pyoderma gangrenosum-like lesions (53, 152, 175–191); see figure 10. These diverse lesions reflect involvement of the subcutis and/or the dermis by gummas, granulomatous nodules, or psoriasiform and granulomatous inflammation.…”

“…Syphilitic leukoderma is a term applied to the depigmented areas, which are most frequently seen on the neck and shoulders (18); they typically appear during the healing stage of secondary syphilis (199). Treponemes have been identified in leukoderma syphiliticum by electron microscopy (200), and in cutaneous gummas by direct immunofluorescence (53), immunohistochemistry (41)(JA Carlson unpublished data), and PCR (41, 56) (see table 2). In addition to the infectious and inflammatory granulomatous disorders listed above, the differential diagnosis should include non-melanoma skin cancers, for late syphilids that show heaped margins around a central ulcer (due to pseudoepitheliomatous epidermal hyperplasia), or for those late syphilids occurring around oroficial sites.…”

Syphilis

“…Im Zentrum der Granulome können Nekrosen auftreten. Mit sensitiven Methoden [9] lassen sich zwar noch Treponemen in Gummen nachweisen,sie gelten jedoch nicht als infektiöse Läsionen.…”