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Perineal syphilitic gumma: tertiary syphilis in a developed country
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  1. Ana Mesquita Varejão,
  2. Diana M Monteiro and
  3. Catarina Peixinho
  1. Obstetrics and Gynecology, Unidade Local de Saúde de Matosinhos, E.P.E, Matosinhos, Porto, Portugal
  1. Correspondence to Dr Ana Mesquita Varejão; anabarbara.varejao{at}gmail.com

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Description

A woman in her 30s presented to the emergency department with extremely painful confluent ulcerated lesions of the perineum (figure 1) and inguinal fold (figure 2). The ulcers were gelatinous and partially covered by a yellowish exudate. She reported indolent evolution of the lesions over the past 3 months, with fluctuating intensity of pain and burning symptomatology, without regression of the lesions. She had been treated with topical steroid therapy and antibiotics without improvement. She denied other symptoms such as fever, malaise or weight loss. She was previously healthy and reported casual unprotected sexual intercourse, more than 3 years ago. She denied history of sexually transmitted infections, intravenous drug use, contact with animals or recent travel abroad. Differential diagnosis may be considered: primary syphilis usually begins with a single, painless, well-demarcated ulcer with a clean base and indurated border. Herpetic ulcers (the most prevalent cause) are painful and usually last 7–10 days. Behçet’s disease and Lipschutz ulcers were also considered, but the patient had no history of other mucosal ulcerations or systemic disease.

Figure 1

Confluent ulcerated lesions of the perineum.

Figure 2

Lesion of the inguinal fold.

Punch biopsy of the lesions showed significant inflammatory infiltrate with suppuration and serological tests came back positive for syphilis (VDRL - Venereal Disease Research Laboratory positive) and negative for hepatitis B and C and HIV and the diagnosis of tertiary syphilis was established.

She was treated with three doses of 2.4 million units of benzathine penicillin G intramuscular injections during the course of 3 weeks. The lesions showed significant improvement after the first dose of treatment and were completely healed at the end of treatment (figure 3).

Figure 3

Completely healed perineum 3 months after completing treatment.

According to the WHO, 12 million new cases of syphilis are reported per year worldwide, with only 10% of cases occurring in developed countries. Nevertheless, in Portugal, between 2000 and 2014, there was a significant increase in syphilis hospitalisation rates.1 We report an extremely rare case, nowadays, of a syphilitic gumma, a form of cutaneous tertiary syphilis, in an immunocompetent patient.

Approximately one-third of untreated syphilis results in tertiary syphilis, and the progression to this stage ranges from several months to 35 years after infection.2 3 The most common clinical forms of tertiary syphilis are neurosyphilis, cardiovascular syphilis (syphilitic aortitis) and gummatous syphilis.4 Syphilitic gummas account for approximately 16% of tertiary syphilis manifestations and are rarely contagious.3 They present as rounded or oval subcutaneous nodules measuring 2–10 cm and constitutional symptoms are usually absent.2 The size of the gummas is highly variable, but severe lesions, also known as rupioid lesions, have been described in malnourished patients.4

Cases of cranial, facial, hard palate and other syphilitic gummas have been reported in literature.3 5 6 To the best of our knowledge this is one of the first descriptions in literature of vulvar and perineal syphilitic gummas in an immunocompetent patient from a developed country.

Learning points

  • The most common clinical forms of tertiary syphilis are neurosyphilis, cardiovascular syphilis (syphilitic aortitis) and gummatous syphilis.

  • Differential diagnosis of syphilitic gummas should include primary syphilis ulcer, herpes, chancroid, Behçet’s disease, Lipschutz and other causes of genital ulceration.

  • Syphilitic gummas account for approximately 16% of tertiary syphilis manifestations and are rounded or oval subcutaneous nodules measuring 2–10 cm with constitutional symptoms usually absent.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors AMV was responsible for literature revision and article writing. DM was responsible for patient admission, and revision of the article. CP was the patient’s assigned medical doctor and was responsible for article revision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.