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A m J R o.n tg .n ol 127 :7 89 -7 92 . 1 976 78 9
Rad iog raph ic F ind ings in E ar ly A cqu ired Syph ilis :C
ase R epo rt and C ritic a l R ev iew
IRVING EHR LICH AND MORR IE E . KR ICUN
Dis cuss ionThe rad iog raph ic and pathophys io lo g ic fea tu
res o f ea rly
acqu ired syph ilis a re d iscussed . Bone changes occu r inea
rly a cqu ired syph ilis and shou ld no t b e con fu sed w ithgumm
as o f la te syph ilis . T h e rad iog raph ic find ing s a repro
te an and m ay ex is t w ith ou t a c lin ica l h is to ry o f acu
tan eous les io n . Th e sku ll, c la v ic le , a nd tib ia a re th
e s ite sm os t fre quen tly in vo lv ed .
In t roduc t ionThe osseous changes o f ea r ly acqu ired syph
ilis a re ra reand have no t b een em phas iz ed in rec en t rad io
lo g ic lite ra -tu re and te x tbooks on bone d is e ase ( 1-3 j.
W e re cen tlyexam ined a case of syph ilitic o s teope rio s titis
tha t occu rreddu ring the ea rly phase o f the seconda ry s tage o
fth is d ise ase .
Case R epo rtA 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 iths 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 ism usc le and jo in t pa in began
. The re w as no h is to ry o f syp h iliscon tac t o r trea tm en
t fo r syph ilis . P hys ica l e xam ina tion showeda 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 fth 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 nw 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 dthe 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 theco rte x o f th e tib ia e ,
fibu la e , u lna e , an d rad ii ( figs . 1 and 2 ) w iths 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 ld 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 la 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 rep resen t in th e sku ll,
c lav ic les , o the r lo ng bone s , rib s . sp in e , o rfee 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 resw 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 thein 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 epen 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 ceo 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 teres 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 tit w
as no t u n til 1 932 th a t rad iog raph ic ev idence o f
osseouschange 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 iseaseis ra re . In 1942 , R eyno lds and W asse rm an [71
rev iewed1 5 cases repo r te d be tw een 1 932 and 1 940 and added1
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 00pa tien ts w ith ea rly acqu ired syph ilis ove r a 21 yea r
pe r iodfrom 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
rin 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 resBone 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 reseve 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 . Thecha ra c te ris tic de rm a to lo g
ic ch ange o f se conda ry syph ilisis a m acu lop apu la r ra sh o
ve r th e pa lm s and so le s . It m us tb e rea lize d th a t e a
rly s yph ilit ic o s teom ye lit is m ay oc cu rw itho u t a h is
to ry o f p rim ary o r s econda ry cu tan eou sle s ions and , in
fa c t, m ay deve lop a sho rt tim e a fte r b loodtra n s fus ion
[1 6 , 2 0 ]. A lso , the se ro lo g ic te s t fo r syp h ilism ay
no t b e po s itive w hen bone les ion s o ccu r [5 . 1 71 .
Pathophys io logyThe 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 iliso f b one beg ins as an os te om ye litis
in the m edu lla ry sp aceand sp re ads b y w ay o f b loo d vesse
ls in th e H avers ia ncana 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
bym 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 rchanges 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 ebone 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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2 . G reen fie ld G B : R ad io lo gy o f B one D isea se s , 2d
ed . P h ila -de lph ia , L ip p inco tt. 1 975
.: . C 3 , M U rra y RO , J acobson HG : T h e R ad io log y o f
S ke le ta l D is -o rd e rs . E xe rc ise s in D iag no s is . B a
ltim o re , W illiam s & W ilk in s ,
EARLY ACQUIRED SYPHILIS 79 1
- R efe ren ce s 37 -4 8 . w h ile no t c ited . ha ve b een inc
lude d fo r thein te re sted re ad er .
da ry is chem ia and caseation necros is -the gumm a o fla te s
yph ilis [1 7 ].
A na tom ic D is tr ib u tionThe sku ll a nd c lav ic le , fo
llow ed by th e t ib ia , h um eru s ,
u ln a , and rad iu s , a re th e s ite s m os t fre quen tly in
vo lv edin e a rly acqu ire d s yph ilis . O the r s ites re po
rted w ith le ssfrequency a re the fem u r, fibu la , s te rnum , r
ib s , scapu la ,bones o f th e hands and fee t, n a sa l bones ,
fa c ia l b ones ,p a la te , k n ee , ile um , isch ium , and sp
in e .
Rad io g ra p h ic F ea tu re sThe response o f bone to the sp
iro che te a tta c k in ea r ly
acqu ired syph ilis depends on the v iru lence o f the o rgan
ism ,hos t response , and th e area o f bone in vo lv ed . P e rio
s tit is ,os teom ye litis , and os te itis m an ife s ted by pe
rio s tea l reac-tion , bone destru c tion , o r sc le ros is m ay
occu r a lone o rin com b ina tion and m ay be loca lized or d iffu
se . P e rio s tea lreac tion is usua lly lam ina ted o r so lid ,
bu t can be pe rpen -d icu la r s im u la ting an os teosa rcom a
[1 7 , 28 , 33 ]. O s teo -m ye litis causes os teo ly tic changes
in the co rte x andm edu lla ry space , usua lly w ith an agg ress
ive pa tte rn o fb on e d es tr uc tio n.
S ku ll le s ions appea r as irregu la r a reas o f bone destruc
-tion ; the ou te r tab le is m o re frequen tly in vo lved than
thed ip loae and inne r tab le . The re m ay be so ft tissue swe
llingand w avy pe rio s tea l reac tion [7 ].
In the long bones seques tra tion [1 7 . 31 ], patho log icfra c
tu re [6 , 31 , 3 4 ], e p iph ysea l se pa ra tion [3 1 ], and
evensyph ilitic a rth r itis [32 ] m ay occu r as seque lae . S
equestrain syph ilis a re d ifficu lt to v is ua liz e rad iog raph
ica lly becausethey a re sm a ll and usua lly occu r in cance llous
bone [17 ].It s hou ld be s tre ssed tha t the des tru c tive le s
ions in ea rlyacqu ired syph ilis a re those o f os teom ye litis
and do no trep resen t gum mas.
D iffe re n tia l D iag no s isSyph ilis has long been ca lled
the g rea t im ita to r, and the
d iffe rentia l d iagnos is o f bone changes re fle c ts th is s
ta te -m en t. A gg ress ive -appea ring os teom ye litis w ith o r
w ithou tpe rio s titis m ay s im u la te pyogen ic os teom ye
litis , m e tas ta ticd ise ase , h is tio c y tos is , lym phom a,
leu kem ia , tu b ercu lo s is ,funga l d isease , and Ew ing s sa
rcom a [7 , 1 3, 1 7, 27 , 29 ,34 -3 6 ]. A n os teoper io s titis
m ay s im u la te o s teogen ic sa r-coma [17, 28, 33].
ACKNOW L EDGMEN TSD rs . H ugh B enne tt an d Rona ld S hore we
re re spon s ib le fo r
pr im a ry ca re a nd fo llow -up o f th is p a tien t. W e tha
nk C aro lG arifo fo r exc e lle n t se c re ta ria l ass is ta nce
.
R EFER EN CES1 . E de ik en J , H odes P J : R oen tg en D ia gn
os is o f D ise ases o f
Bone. 2d ed . B a ltim o re , W illiam s & W ilk in s , 1
973
19714 . L an ce reau x E : L es os t# {2 33 }ite s syph ilit iq
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Syph ilig r (P a ris) 7 : 2 6 1 , 18865 . N itch ew L : A pro
pos des o s t# {2 3 3 }o -p # {233 }rio s tite syph ilit iq u es p
r# {2 3 4 }-coces . A nn M a lad Vener 27 :6 00 -6 05 , 1 9326 . G
ougero t M M , M a th ieu P . Ja is : F ra c tu re s pon ta n# {2
33 }e de Ia
c lav icu le a u debu t de Ia syph ilis se conda ire . A nn M a
!adVene r2 7 :3 1 , 1932
7 . R e yno lds FW , W asse rm an H : D e s tru c tive os seou s
le s io n sin e arly syp hilis . A rch In te rn M ed 69 :263 -276 ,
1942
8 . B aue r M F , C a ra va ti C M : O s te o ly tic le s io ns
in ea rly sy ph ilis .B r J V ene r D is 43: 1 75-1 77, 1967
9 . B lo om P : D e s truc tive os te it is a nd fac ia l pa ra
lys is in s econ -d ar y s yp hilis . A rch De rm a to ! S yph 29
:940 , 1934
10 . B u rrow s H J : P a th o lo g ica l fra c tu re o f the
hum e ru s com p li-ca tin g la te se condary s yph ilis . B r J S
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1 1 . Cabane l G . P he lip X , G in tz B : O s t# {23 3 }
iteran ien ne la cuna ire d eIa s yp hilis se co nd aire . P resse
M ed 79 :1 755 -1756 , 1 971
1 2. D illing h am FH , M cC a ffe rty LK : B one syph ilis . Am
J Syph10 :3 78 -3 82 , 1 9 2613 . E x le y M . N ew to n AW : O
sseou s syph ilis . N Eng !J M ed 234 :
661 -664 , 19 461 4. F a rin a A : S u un caso d i o s te om ie
lite g um m osa ne l pe riod o
p re coce de lla lue . G M ed M i! 87 :5 9 , 19 391 5. L e fko v
its AM , C ro ss KR : B one le s ion s in ea rly s yph ilis .
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. Sape rs te in A N : T ra nsm is s io n o f syp h ilis b y
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ife s ta tion sdu rin g se co ndary s yp h ilis . N Y S ta te M ed
J 38 :788 -795 ,193819 . Pa rke r JD J : U n comm on com p lica t
ion s o f ea rly syph ilis .Hepa tit is , pe rio s tit is . ir it
is w ith p ap illit is . a n d m en in g itis . B rJ V ener D is
48:32 -36 , 1972
20 . P i# {22 5 }nC . F raz ie r C N : T ran s fu s io n s yph
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22 . T auber EB , G o ldm an L : S yph ilit ic a n em ia w ith d
iffus e o s te it isa n d s u pe ri nf ec ti on . Am J Syph Neuro l
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24 . Thom pson AG . P re s ton RH : L e s io n s o f the s ku ll
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79 2 EHRL ICH AND KR ICUN
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