Winning Abstracts from the 2013 Medical Student Abstract Competition: Secondary Syphilis: Much More Than a Rash
Author: Catherine L. Meeker, Oregon Health & Science University School of Medicine, Class of 2014
Introduction: The characteristic feature of secondary syphilis is a rash, but its lesser-known symptoms create a presentation that can mimic mononucleosis, primary HIV, or other clinical entities. We report the case of an uncommon presentation of syphilis in a patient who presented with abdominal pain, B-symptoms, and a large abdominal mass concerning for a GI lymphoma.
Case Presentation: A previously healthy 20 year-old homosexual male presented to our medical center with one week of fevers, chills, night-sweats, and severe epigastric pain, three weeks after being evaluated at an outside urgent care center for a sore throat and penile irritation, both of which resolved in the interim period. Triage vital signs were T 37.9 °C, HR 128, RR 16, BP 119/49, Sp02 98% RA. Physical exam was notable for a thin, pale Caucasian male with severe epigastric tenderness to palpation without peritoneal signs. Non-tender bilateral 1cm inguinal lymph nodes were appreciated. Genital exam was otherwise unremarkable. An abnormal abdominal ultrasound in the ED prompted a CT, which revealed a periportal soft tissue mass measuring 2.5x7.0x8.5cm with multiple aortocaval and periaortic lymph nodes. Admission labs were remarkable for a WBC of 18.9K/mm3 with 85% neutrophils and no bandemia. LFTs and lipase were normal.
An excisional biopsy of an inguinal lymph node was pursued.
chemical analysis of the specimen was negative for lymphoma and prototypical viruses. Similarly, serum PCR assays for EBV, CMV, HHV-6, and HIV were negative. With supportive care, his symptoms abated with concomitant normalization of his WBC. However, his alkaline phosphatase steadily rose, peaking at 319U/L. He was discharged on hospital day 7 with close outpatient follow up.
At his follow-up clinic visit, the patient was found to have continued elevation of alkaline phosphatase with new thrombocytosis to 739K/mm3. Further scouring of literature prompted sending an RPR, which came back reactive. State lab FTA testing confirmed the diagnosis of syphilis. He was treated appropriately with IM penicillin G with subsequent resolution of his symptomatology and laboratory derangements.
Discussion: In 2010, there were 45,834 new cases of syphilis, with the highest rates among men ages 20-29, with MSM accounting for 2/3 of all new cases of early-stage syphilis. Despite the fact that our patient was 20 years old and homosexual, syphilis was not on our initial differential because he lacked genital lesions, a rash, and/or neurological symptoms. We report this case to highlight the importance including syphilis on the differential for GI lymphoma, and to emphasize the less common signs and symptoms of secondary syphilis, a disease that is easily treatable if recognized early.