Joint Program in Nuclear Medicine
Radionuclide Imaging in Syphilis
Edward B. Cronin, MD
Donald E. Tow, MD
Walter H. Williams, MD
May 13, 1986
Presentation
A 39 year-old male presented with an eight month history
of worsening back and right shoulder 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.
Imaging Findings
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, Tony_Parker@bidmc.harvard.edu