Periostitis in Secondary Syphilis: A Place for Bone Scintigraphy

Abstract

A Saeed MRCOG Department ofGenito-Urinary Medicine, Royal Lancaster Infirmary, Lancaster Summary: Two cases of secondary syphilis are reported with periostitis as the main presenting feature. Technetium-99m bone scintigraphy was found to be superior to radiography in both defining the extent of involvement and in picking up early lesions. Case reportsCase 1: A 35-year-old unmarried Irish woman working as an office secretary was referred to the Rheumatology Clinic at St George's Hospital on 28 September 1983 with a history of pain and tenderness in the neck following a fall from a bicycle at the end of July that year. Three weeks previously she had developed pain, tenderness and swelling over both shins. For one week she had noticed spontaneous bruising over the right shin, right buttock and left thigh, and had felt unwell. On direct questioning she reported that a papular non-pruritic rash had appeared on her trunk two weeks before. This had coincided with taking ibuprofen, started by her general practitioner, and the rash was attributed toz an idiosyncratic reaction to the drug. The rash disappeared three days after stopping the drug. It had lasted for about a week. There was no history of orogenital ulceration. She had been sexually active and her partner travelled abroad frequently.On examination, she was found to be a fit-looking woman, with bruises over the right buttock and anterior part of the right leg. No rash was evident, and no orogenital lesions or lymphadenopathy could be seen. Both tibiae were tender, but there was no pre-tibial oedema. An area of tenderness was found over the lower cervical spine, with limitation of lateral flexion and rotation. The skull and the other long bones were not tender. Neurological and remaining systematic examination were normal.Routine investigations were normal apart from an erythrocyte sedimentation rate (ESR) of 54mm in the first hour, and a leukocytosis of 10.2 x 109/1. Coagulation profile and bone marrow examination were normal. Autoantibody screen was negative. Radiological skeletal survey did not reveal any abnormalities. However, a technetium-99m (99mTc) bone scan showed multiple areas of increased uptake mainly over the skull and long bones, where it was in the form of a streaky linear pattern (Figures 1 & 2). Soon after admission she began to lose the lateral parts of her eyebrows, as well as her eyelashes. A maculopapular, non-pruritic rash appeared on her trunk but faded without treatment over three days.Serology for syphilis was then assessed: rapid plasma reagin (RPR) card test positive 1:128, treponemal haemagglutination (TPHA) positive, fluorescent treponemal antibody (FTA) test positive. Skin biopsy of the rash showed areas of perivascular infiltration with plasma cells, consistent with lesions of secondary syphilis. Treatment with procaine penicillin was instituted (1.2 megaunits intramuscularly for ten days).IPaper arising from presentation ofCase I

A skeletal case of hypertrophic osteoarthropathy from the Canary Islands dating from 1000 BP

“…6), and normal osteons are observed in the histological section, arguing against a syphilitic etiology. The rare cases of syphilitic periostitis associated to secondary syphilis show by far less intense affectation than that observed here (Veerapen et al, 1985).…”

Bone pain as the presenting manifestation of secondary syphilis.

“…A recent paper by Veerapen et al describes two other patients who had normal or only minimal radiographic changes but widespread isotope uptake on bone scan. 2 Our patient declined HIV antibody testing.…”

The disappearance of femoral head and neck resulting from extensive bone defect caused by secondary syphilis: a case report and literature review

“…We retrospectively analysed the English-language literature from 1967 to the first half of 2017 describing patients with secondary syphilis with involvement of long bone of the limbs (Table 1 - 2 ) [ 6 , 13 – 31 ]. Twenty-one (78%) patients were male, and 6 (22%) were female.…”