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A m J R o.n tg .n ol

1 27 :7 89 -7 92 . 1 97 6

78 9

R a d io g ra p h ic F in d in g s in E ar ly A c q u ire d S y p h ilis :

C a s e R e p o rt a n d C ritic a l R e v ie w

IRVING EHR LICH AND MORR IE E . KR ICUN

D i s c us s i on

T h e rad io g rap h ic an d p ath o p h y s io lo g ic fea tu res o f ea rly

ac q u ire d s yp h ilis a re d isc u s se d . B o n e c h a n ge s oc c u r in

ea rly a cq u ired s yp h ilis an d sh o u ld n o t b e c o n fu s ed w ith

g u m m a s o f la te sy p h ilis . T h e rad io g ra p h ic find in g s a re

pro te an a n d m a y e x is t w ith ou t a c lin ica l h is to ry o f a

cu ta n e ou s les io n . T h e s ku ll, c la v ic le , a n d tib ia a re th e s ite s

m o s t fre qu e n tly in vo lv ed .

I n t r oduc t i on

The osseous changes o f ea r ly acqu ired syph ilis a re ra re

a nd h av e n o t b e en e m p h a s iz ed in rec e n t ra d io lo g ic lite ra -

tu re a n d te x tb o o k s o n b o n e d is e as e 1 -3 j. W e re ce n tly

exam ined a case of syph ilitic o s teope rio s titis tha t occu rred

du ring the ea rly phase o f the seconda ry s tage o f

th is d ise ase .

C a s e R e p o rt

A 35 -yea r-o ld b la ck m a le was w e ll

un til 4 w eek s p rio r to

adm iss ion w hen he no ted con s tan t a ch ing pa in in th e ca lves w ith

s ligh t m usc le w eakne ss and a ch in g and te ndern e ss o f the an k le s .

H e no ted an e ru p tion on th e pa lm s and so les a t the tim e h is

m usc le and jo in t pa in began .

The re w as no h is to ry o f syp h ilis

con tac t o r trea tm en t fo r syph ilis . P hys ica l e xam ina tion showed

a w e ll n o u rish ed pa tie n t in n o acu te d is tres s . T he re w ere hyper -

p igm en te d ke ra to tic m acu le s on the pa lm s and so les b ila te ra lly .

com patib le w ith seconda ry syph ilis . The re w as a lso sw e lling o f

th e

p re tib ia l a re a b ila te ra lly . T he rem a inde r o f the exam ina tio n

w a s u nr em a rk ab le .

F lu o re scen t trep onem a l an tib od y ab so rp tio n w as po s itiv e . an d

the rap id p la sm a reag in was reac tiv e a t a 1 :64

d ilu t ion . R ad io -

g raphs d isc lo sed m ultip le agg ress ive os teo ly tic le s ions in the

co rte x o f th e tib ia e , fibu la e , u lna e , an d rad ii ( figs . 1 and 2 ) w ith

s o lid pe rio s te a l re a c tio n in seve ra l loc a tio n s . T he re was m in im a l

d es tru c tion o f the p rox im a l a spec t o f the se cond m e taca rp a l

a lo ng w ith so lid pe rio s te a l re ac tion (fig . 3 ). N o le s io ns w e re

p resen t in th e sku ll, c lav ic les , o the r lo ng bone s , rib s . sp in e , o r

fee t .

B io p sy o f the le ft f ib u la d isc los ed ne cro tic b o ne w ith in flam -

m a to ry ce ll in filtra te com posed m os tly o f m a tu re p lasm a ce lls .

T h e va scu la rity w as p rom in en t a n d th e endo the lia l ce lls w e re

sw o lle n and p le om orp h ic . S p iro ch e te s w e re id en tif ie d w ith in the

in flamm a to ry ce ll exu da te . T he pa th o log ic d ia gno s is w a s s yph i-

litic pe r ios titis a nd o ste itis .

The pa tie n t w a s trea ted w ith 1 2 m illio n u n its o f p roca in e

pen ic ill in in tram uscu la rly ove r a 10 da y pe riod . D uring hosp ita li-

za tion , he deve loped he rpes zos ter and m ollu scum con tag io sum .

Aad iog raphs 1 m on th la te r show ed no change in th e appea ran ce

o f th e les io ns , b u t a fte r 3 m on ths th e re w as a lm os t com p le te

res o lu tio n o f th e le s io n s (fig . 4 ).

O sseous syph ilis w as firs t descr ibed in 1886 [4 ], bu t

it w as no t u n til 1 932 th a t

rad iog raph ic ev idence o f osseous

change in e a r ly a cqu ire d syph ilis w as firs t re po rte d [5 , 61 .

The inc idence o f rad iog raph ica lly d iagnosed bone d isease

is ra re . In 1942 , R eyno lds and W asse rm an

[71 rev iewed

1 5 cases repo r te d be tw een 1 932 and 1 940 and added

1 5 o f the ir ow n . T he ir c as es cam e from a se rie s o f 1 0 ,0 00

pa tien ts w ith ea rly acqu ired syph ilis ove r a 21 yea r pe r iod

from 1 91 9 -1 940 . B one les ion s have been dem on-

s tra te d rad io g raph ica lly in a to ta l o f 52 re po rte d case s ,

inc lu d ing the p re sen t case [5 -261 . O sseous changes occu r

in 0 .1 5% -8 .7% o f

pa tien ts w ith ea rly acqu ired syph ilis [8 ].

C lin ica l F ea tu res

Bone changes occu r as ea rly as 6 w eeks a fte r the

prim a ry c hanc re to as la te a s 14 m on th s a fte r th e secon -

d a ry sk in e rup tio n . In se ve ra l ca se s , b one change s de -

ve lo ped w ith th e cu tan eou s e rup tio n o f s econda ry sy ph ilis

[7 ]. T he deg re e o f b o ne de s tru c tio n is u sua lly m o re

seve re than the c lin ica l sym p tom a to logy [27 -29 ]. C lin -

ica lly th e re m ay be pa in , s o ft t iss ue swe llin g , te nde rne ss ,

headache, fe ve r, and o the r cons titu tiona l sym p tom s . The

cha ra c te ris tic de rm a to lo g ic ch ange o f se conda ry syph ilis

is a m acu lop apu la r ra sh o ve r th e pa lm s and so le s . It m us t

b e rea lize d th a t e a rly s yph ilit ic o s teom ye lit is m ay oc cu r

w itho u t a h is to ry o f p rim ary o r s econda ry cu tan eou s

le s ions and , in fa c t, m ay deve lop a sho rt tim e a fte r b lood

tra n s fus ion [1 6 , 2 0 ]. A lso , the se ro lo g ic te s t fo r syp h ilis

m ay no t b e po s itive w hen bone les ion s o ccu r [5 . 1 71 .

Pathophys io logy

The sp iro che tem ia and m ucocu taneous le s ions o f secon -

dary syph ilis oc cu r 1 -3 m on th s a fte r the p rim ary chan cre .

D u rin g th is s tag e , sp iro che tes m ay be d is sem in a te d hem a-

togenous ly th roughou t the body and found in the pe rio s-

teum , H a ve rs ian cana ls , a n d m edu lla ry sp ace o f a ll bo nes

[3 0 ]. S eve ra l in ve s tig a to rs [2 5 , 3 1 , 3 2 ] s ta te tha t sy ph ilis

o f b one beg ins as an os te om ye litis in the m edu lla ry sp ace

and sp re ads b y w ay o f b loo d vesse ls in th e H avers ia n

cana ls to the co rte x and perios te um .

Sp iro che tes induce a pe riv ascu la r re sponse fo llow ed by

m uscu la ris a trophy , endo the lia l p ro life ra tion , and subse -

quen t enda rte ritis ob lite rans [17, 30 ]. T hese vascu la r

changes a re the cause o f os teochond ritis , pe rio s titis ,

o s te it is , o r

osteom ye litis depend ing

on wh ic h pa rt o f th e

bone is in vo lve d . T he va scu la r ch ange s le a d la te r to secon -

R ec ei ve d M ar ch

15 , 1976 ;

accepted

a fte r rev is io n June

16 .

1976 .

D e pa rtm en t o f D ia gno st ic R ad io log y , H ahnem ann M ed ica l C o lle ge a nd H osp ita l.

230 N orth B road S tree t, P h ilade lph ia . P ennsy lvan ia 19102 . Address

rep rin t req ue sts to M . E . K r icu n .

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79 2

EHRL ICH AND KR ICUN

2 8 . S a n te L A :

R ad iog ra ph ic m an ife s ta tion s o f syp h il itic d isea se s

ofbone AmJSyph

12 :5 10 -5 16 , 1 928

29 . U nge rm an AH , V ica ry W H . E ld r idge WW : Lue tic os te itis

s im ula ting m a lig n an t d isea se .

Am J R oen tge no l

40 :224 -

2 2 9 . 19 38

30 . R obb ins SL :

P ath o log ic B as is o f D is ea se .

Ph i lade lph ia ,

S aunde rs , 1 974

31

.

Speed JS .

B oyd HB : B one syph ilis .

S ou th M ed J

29 :371

-

377, 1936

32 . W a re MW : S yph ilis o f the bones and som e rad iog raph ic

f i nd ings .

Ann Su rg

46 :1 99 -2 05 , 1 907

33 . S kap inke r S . M innaa r D : S yph ilitic d isease o f the long bones

in the Ban tu . J B one Jo in t S u rg 33 -B :5 78 -5 83 , 1 9 51

34 . O lm s te ad EG : G umm ato us o s te om ye lit is w ith pa tho lo g ic

frac tu re com p lica ting genera l p a res is .

Am J Syph 32 :243 -

250 , 1948

35 . C a rm an AD : A re v iew o f the roen tg eno lo gy o f sy ph ilis . Am

JSyph 2 :297 -343 , 1918

36 . Jo hns D : S yph ilit ic d iso rd e rs o f the sp in e . J Bone Jo in t S u rg

52 -B :724 -731 , 1 970

37 . A lexa nde r U , S cho ch AG : O sseou s syph ilis . Am J Syph

G onn Vene r D is

26 :397 -406 , 1 942

38 . B a ile y GG : M an ife s ta tion s o f bo ne syph ilis .

U ro l C u t R e v

49 :11 -1 2 , 1 945

39 . B in g o ld AC : L ue tic lum bar sp ond y lit is .

P ro c R S oc M ed

55 :3 54 -3 55 , 1 962

40 . F ranc is HC , K am pm eie r RH : The bone les ions in a cq uire d

te rtia ry s yp hilis .

Sou th M ed J

36 :556 -559 , 1 943

41

.

H o lm es GW .

L ing ley JR : R oen tg eno lo g ic m an ifes ta tio ns o f

syphil is . N E ng lJ M ed

217 :983 -987 , 1 9 37

42 . K a ra h a rju E O . H a n nu k s e la M : P o ss ib le sy p h ilitic s p o n d y litis .

A cta O rtho p S cand

44 :289 -295 , 1973

43 . N a th an AS , L aw son W : S yph ilit ic o s teom ye lit is o f the

mand ib le . O ra l S u rg

1 7:2 84 -2 88 , 1 964

44 . R o s t G S : R oen tg en m an ife s ta tion s o f B e je l (e ndem ic s yph i-

lis ) as ob se rve d in the Euph ra te s R ive r V a lle y .

Rad io logy

38 :320 -325 , 1942

45 . R o y R B , L a ird SM : A cu te p e rios tit is in e a rly acqu ire d

syphil is . Br J Vener Dis 49 :555 , 19 73

46 . S tew a rt DM : R oen tg eno lo g ica l m an ife s ta tion s in bon e syph i-

lis . A m J R oe ntg en ol 40 :2 1 5 -223 , 1 9 38

47 . S to kes JH , B eerm an H , In g raham NR Jr:

Modern Clinical

Syphilology 3d ed . P h ila de lp h ia , S aunde rs , 19 44

48 . W ile U J, S enea r F E : A stu dy o f th e in vo lvem en t o f th e b one s

and jo in ts in ea rly sy ph ilis . Am J M ed Sc i 1 52 :6 89 -6 93 ,

1 9 16