Winning Abstracts: Pretending to be the Great Pretender

John Cao MS21 (Co-First Author), Waldo Zamor BSc1 (Co-First Author), Anthony Esposito MD FACP2, Dori Goldberg MD1, Jane Lochrie MD FACP2

1University of Massachusetts Medical School
2Department of Medicine Saint Vincent Hospital Worcester MA

Introduction: The Treponema pallidum species of bacteria has been called “Treponema pretendium” for its ability to mimic other infectious and non-infectious diseases. The Treponema genus has at least four subspecies that cause disease in humans. Infection by spirochetes continue to be a preventable cause of morbidity and mortality worldwide. Of the Treponema pallidum species, most familiar is Treponema pallidum pallidum, the spirochete known to cause syphilis. The other Treponema pallidum subspecies continue to be diagnostic challenges.

Case: A 46 year-old male visiting from Ghana presented with a three day history of itching papules. The patient reported malaise, diffuse myalgias, and feeling febrile prior to the cutaneous papular eruption. The papules began on his face and spread caudally. He has no recent medical or family history, no known allergies, and is not taking medications. The sexual history revealed no recent history of genital chancre and no recent new sexual partners.

On physical examination, his vital signs were normal. The skin exam revealed diffuse 2-5mm flesh colored papules and papules coalesced into plaques on the face. There was no palmar, plantar, or genital involvement. Examination of the lymph nodes and oral mucosa showed no significant findings. The neurological exam was similarly unremarkable.

A number of etiologies were initially suspected, including viral exanthem, HIV-associated folliculitis, and secondary syphilis. Lab results showed a negative HIV antigen test; however, the RPR was reactive with a 1:4 titer. The confirmatory FT-ABS test was also positive.

His presentation was consistent with yaws. He was treated with 2 grams of azithromycin, as recommended in recent literature, and reported feeling well after treatment. On two week follow up the lesions resolved, leaving only mild scarring and post-inflammatory hyperpigmentation. No Herxheimher reaction to the antibiotic was reported.

Discussion: Yaws is a treponemal infection that is contagious through non-sexual skin contact. Left untreated, yaws can cause disfiguring skin lesions and bone, cartilage, and soft tissue destruction. It should be suspected in patients from endemic countries such as Ghana, Cote d'Ivoire, and Papua New Guinea. There is a current World Health Initiative to eradicate yaws worldwide; this program has successfully eradicated Yaws in India.

By recognizing the presentations and endemic areas of yaws, a healthcare professional can help eradicate this highly transmissible and potentially disfiguring treponemal disease that has a low cost of treatment and high cost if left untreated.

ACP holds a National Abstracts Competition as part of the ACP Internal Medicine Meeting every year. Find out more about the ACP National Abstract Competition.

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