RADIONUCLIDE IMAGING IN SYPHILIS

Edward B. Cronin, M.D.

Donald E. Tow, M.D.

Walter H. Williams, M.D.

May 13, 1986

Case Presentation:

A 39 year-old male presented to the EW with an eight month history of worsening back and right should pain accompanied by a twenty pound weight loss. Radiographs in the EW demonstrated multiple lytic and blastic lesion to the spine (A-P and lateral) and destruction of the right glenoid (arrow); he was then admitted for workup of presumed metastitic carcinoma. Twenty years earlier, he had undergone an orchiectomy for an undescended testicle and had been treated in 1967 for urethritis while in Vietnam. Physical examination was remarkable only for hepatomegaly. His hematocrit was 36%, ESR 122mm/hr, iron 18, TIBC 204, alkaline phosphatase 199; other liver function studies were normal. CEA, AFP, SPEP and B-HCG levels were normal. A Tc-99m MDP bone scintigram demonstrated multiple regions of increased and decreased activity (right shoulder, left shoulder, LS spine); a Tc-99m sulfur colloid liver spleen scan showed hepatomegaly with multiple focal liver defects. A CT scan confirmed the presence of liver defects and destructive change in the spine. A bone biopsy was unsuccessful and two liver biopsies yielded no neoplastic cells. He underwent an exploratory laparotomy and was found to have several caseous liver masses, but no tumor. An infectious etiology was felt most likely and syphilis serologies were obtained. The RDRL was positive at 1:128, FTA-abs 4+ and CSF VDRL was also positive. He was begun on penicillin therapy. Following treatment, he had resolution of his back pain and began to gain weight.

Discussion:

Although about 25,000 cases of primary or secondary syphilis are diagnosed annually in the United States, tertiary syphilis is rare. Since the introduction of antibiotics in 1940, deaths due to syphilis have declined by 99%. Syphilis is acquired through sexual or close contact with active chancres on skin or mucous membranes, or by transfusion or needle puncture of infected material; in the congenital form, it is acquired transplacentally. Primary syphilis is manifested by the chancre at the site of inoculation and by regional adenopathy. Secondary syphilis may be manifested by a diffuse skin rash, and systemic symptoms which may include bone pain and hepatitis. Signs of symptoms generally subside spontaneously after 3-6 weeks and the disease then enters a latent phase. This can last 10 to 30 years; tertiary syphilis will then develop in about half of these patients, manifested by cardiovascular disease, neurosyphilis and gummata. A gumma may be found in any organ, but skin and bone are the most frequent sites. The organism may be recovered from active chancres, but it is rarely found in gummata; in late syphilis the diagnosis must be made by serological testing and by recognition of suggestive pathologic features of the gumma.

The liver may be involved in secondary or tertiary syphilis. Hepatitis and occasionally cholestatis are the most common manifestations in the secondary form; this is typically a nonfocal process and may be progressive. Gummata are seen in tertiary syphilis and in all recent case reports have been mistaken preoperatively for tumor. In the liver they may be up to several centimeters in size and because of their makeup would be expected to appear similar to other space occupying lesions such as tumor or abscess.

Osseous disease is also seen in both secondary and tertiary syphilis. Blood borne organisms are deposited in the deep periostium in early disease, causing an inflammatory periostis, osteochrondritis or osteomyelitis to occur. Proliferative periostitis has been well described in secondary syphilis and is most commonly seen in the tibiae, skull, clavicles, ribs and sternum. Scintigraphy is a sensitive mean of detection in subtle cases and can be useful in determination of extent of disease for guiding bone biopsy. Osteomyelitis is less common, but is recognized as causing a destructive or moth-eaten appearance on x-ray and can be identified on bone scanning. Bone lesions in tertiary syphilis may be due to gummata, periostitis or osteomyelitis. Radiographically, these processes produce a mixed lytic-blastic appearance, bone destruction and pathologic fractures. The skull, facial bones, appendicular skeleton, spine and pelvis may all be involved by these processes. There are no reports of the scintigraphic findings in late syphilis of bone.

References:

1) Jaffe HL. Syphilis of bones and joints. Metabolic degenerative and inflammatory disease of bones and joints. Philadelphia, Lea and Febiger. 1972; Ch. 29.

2) Resnick D and Niwayama G. Osteomyelitis, septic arthritis and soft tissue infection: the organisms. In: Diagnosis of bone and joint disorders. Philadelphia, Saunders. 1981; Ch. 62.

3) Tight R and Warner J. Skeletal involvement in secondary syphilis detected by bone scanning. JAMA 1976; 235:2646-2648.

4) Veerapen K, Brucker F, et al. Periostitis in secondary syphilis: a place for bone scintigraphy. J R Soc Med 1985; 78:721-724.

5) Agrawal N, Sassaris M, et al. The liver in secondary syphilis. South Med J 1982; 75:1136-1138.

6) Parnis R.. Gumma of the liver. BR J Surg 1975; 62:236.

7) Vas W, Thomasson J, et al. CT and ultrasound appearance of liver disease in secondary syphilis. Diagn Imag Clin Med 1985; 54:1-6.

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J. Anthony Parker, MD PhD, jap@nucmed.bih.harvard.edu