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Solitary pulmonary nodule in secondary syphilis
CLINICAL
IMAGING
1992;16:125-128
125
SOLITARY PULMONARY NODULE IN SECONDARY SYPHILIS JOHN V. CHOLANKERIL, MD, FACR, ALAN-LIN GREENBERG, MD, HUSSEIN M. MATARI, MICHELLE R. REISNER, MD AND ABRAHAM OBUCHOWSKI, MD A case of secondary syphilis with a solitary right upper-lobe nodule is presented. Patient presented without any pulmonary complaints or findings. This mass disappeared with residual scar after a full course of penicillin therapy. Our report is the first in the literature that reports a solitary nodule in the upper lobes in secondary syphilis. Previous reports showed nodules only in lower lobes. Our patient also presented with a rectal mass that disappeared on antisyphilitic therapy.
MD,
for which there may be two reasons: 1) these lesions are rare in secondary syphilis; and 2) pulmonary symptoms may not be recognized because most of these patients are not hospitalized and chest x-rays are not performed (4). We report a case of secondary syphilis with a solitary right upper lobe nodule and a rectal mass. The pulmonary lesion cleared with residual small fibrotic area after a full course of penicillin treatment. The rectal mass also disappeared completely.
KEYWORDS:
Syphilis: Spirochete; Pulmonary nodule; Rectal mass; Lymphocytes; Plasma cells
INTRODUCTION The incidence of syphilis has been rising in the United States, particularly in the homosexual population (1, 2). In 1944, Stokes mentioned three clinical forms of acquired pulmonary syphilis-gumma, diffuse bronchopneumonia, and diffuse fibrosis (3). Congenital pulmonary infiltration (pneumonia alba) is also well known. Pulmonary lesions have most commonly been reported in tertiary syphilis with histology of gumma (3). There have been very few reports of lung involvement in secondary syphilis
From the Department of Radiology (J.V.C., H.M.M., A.O.) and from the Department of Medicine (A-L.G., M.R.R.), Jersey City Medical Center, Jersey City, New Jersey. Address reprint requests to: John V. Cholankeril, MD, FACR, Vice President and Dir. of Radiology, Jersey City Medical Center, 50 Baldwin Avenue, Jersey City, 07304. Received August 1990; revised April 1991; accepted September 1991. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010 0899-7071192/$5.00
CASE HISTORY A 33-year-old Hispanic man was hospitalized for evaluation of a rectal mass. He had been in good health until 1 month prior to entry, when he noted a generalized rash, and experienced anorexia associated with a 12 lb weight loss. He denied pulmonary symptoms or exposure to tuberculosis. He had multiple heterosexual partners. He was born in Cuba, and had come to the United States about 1 year before admission. During this time he was in and out of jail. He denied any homosexual contact. Physical examination was significant for a generalized symmetric pale-red maculopapular rash that did not involve the palms or soles. Generalized nontender adenopathy was present, and a smooth lobulated lesion was palpated on rectal exam. Chest x-ray and tomograms showed a nodular mass density 3 x 2 cm in the anterior segment of the right lobe without calcification (Figure 1).Barium enema and pelvic computed tomography CT showed a submucosal mass in the proximal rectum (Figures 2 and 3). A rapid plasma reagin (RPR) test was positive with a titer of 1 : 128, and a confirmatory FTA-AB was positive. Sputum cytology and cultures were nega-
126
CHOLANKERIL ET AL.
CLINICAL IMAGING VOL. 16. NO. 2
B FIGURE 1. 3 x 2 cm nodule projecting in the anterior segment of right upper lobe. tive. The liver function tests were elevated. Biopsy of the rectal mass demonstrated chronic inflammatory changes, and a Warthin Starry silver stain revealed spirochete forms consistent with Treponema pallidum. Biopsy of a skin lesion showed plasma cell and histiocytic perivascular infiltration with obliterative endarteritis consistent with secondary syphilis. A diagnosis of secondary syphillis with cutaneous, rectal, and probable pulmonary involvement was made. Several hours after treatment with benzathine penicillin was initiated he experienced a typical Jarisch-Herxheimer reaction. He received a total of two doses of intramuscular benzathine penicillin of 2.4 million units each, 1 week apart. Over the next 6 weeks he experienced complete resolution of all his clinical findings, including disappearance of the pulmonary nodule (Figure 4). DISCUSSION Pulmonary lesions in secondary syphilis are extremely rare. There are only a few case reports in
B FIGURE 2. Barium enema shows submucosal lesion in the rectosigmoid region, without obstruction of the flow of barium.
the literature. Coleman et al. (2) reported a case with bilateral lower lobe infiltrates, Biro et al. reported (5) bilateral nodular infiltrates in the lung bases. Gadske reported two cases (4, 6) one with lace-like pulmonary infiltrates in the chest x-ray; the other revealed bronchopneumonia at autopsy. Impens et al. reported a case (7) of right pleural effusion. Schibli et al. (3) and Geer et al. (1) reported solitary pulmonary nodules in the lung bases. Pulmonary lesions in secondary syphilis can manifest as bilateral bronchopneumonia, bilateral solitary or multiple nodules, pleural effusion, or lymphadenopathy (l-4, 6, 7). When they present as nodules, differential
APRIL-JUNE
PLJLMONARY
1992
FIGURE 3. CT demonstrates thickening of rectal wall.
submucosal
NODULE
IN SECODAKY
SYPHILIS
127
mass lesion with
diagnostic considerations should include infection [tuberculosis fungus, bacterial, viral), primary or secondary lung tumors, sarcoidosis, infarction, hematoma, lymphoma, pseudotumor, Wegners, Septic emboli, Kaposi sarcoma, Collagen disease, bronchiectasis, etc. (6, 3). In the previous reports, lung lesions showed a preference to lung bases as well as unilateral involvement (1, 8). Our case appears to be the first case report in the literature of a solitary nodule in the upper lobe in secondary syphilis. There are few references in the literature in which lung resection was performed because of tumor mass in tertiary syphilis (1). In large autopsy series the incidence ranged from 0.25%-12% with most lung lesions in tertiary syphilis (1). All the lung lesions in secondary syphilis reported in the literature, including ours, with the exception of Kurumaji et al. (6) did not have a lung biopsy. Kurumaji et al. report that their case showed poorly differentiated granuloma similar to epithelioid granuloma seen in the patient’s skin biopsy surrounded by lymphocytes and multinucleated cells (6). Classic examples of histopathology in secondary syphilis are perivascular cell infiltrate with plasma cells and endothelial damage to blood vessels as seen in the skin biopsy of our case. Plasma cell infiltration can be sparse or absent in some cases with very little vascular damage (6). Recently Coleman et al. have proposed certain criteria for diagnosis of pulmonary involvement in secondary syphilis (2): 1) history and physical findings, typical of secondary syphilis; 2) serologic tests positive for secondary syphilis; 3) pulmonary abnormalities seen radiographically with or without
B FIGURE 4. Resolution of right upper lobe nodule residual scarring after penicillin therapy.
with
associated symptoms; 4) exclusion of other pulmonary disease, by serologic tests, sputum smears, cultures, and sputum cytology; 5) therapeutic response of radiologic findings to antisyphilitic therapy. The diagnosis of secondary syphilis in our case is based on the above criteria. The skin biopsy also showed classic findings. After treatment with penicillin the patient recovered completely. The liver dysfunction seen in this case also disappeared. The patient also experienced mild Jarisch-Herxheimer reaction during the course of therapy.
128
CHOLANKERIL ET AL.
Syphilis must also be considered a leading cause of rectal mass in any young patient as homosexuality increased markedly over the past decade (5, 9). In addition, to the condyloma lata of secondary syphilis, anorectal lesions associated with early syphilis may include polyps, smooth lobulated masses, mucosal ulcerations, erythema and friability in the anus and rectum (9). We could be seeing more pulmonary as well as gastrointestinal manifestations in the future and it is important to familiarize the physician with these findings in different stages of syphilis. In a heterosexual male, a ‘rectal mass could represent a neoplasm or an inflammatory process. Neoplasm can be a malignant carcinoma, carcinoid, various forms of lymphoma, various polypoid syndromes such as familial polyposis, Gardners, PentzJeghers, juvenile polyposis and noncolonic malignancies by hematogenous dissemination, lymphatic spread, intraperitoneal seeding to the pouch of Douglas, and direct invasion from prostate and bladder. Inflammatory process such as hyperplastic polyps and diverticular granuloma or abscess formation can also present as a mass.
CLINICAL IMAGING VOL. 16, NO. 2
We acknowledge our appreciation preparation of this manuscript.
to Mercedes
Rodriguez
in the
REFERENCES 1. Geer KL, Warshauer,
secondary
syphilis.
DM, Delany DJ. Pulmonary nodule Australas Radio1 1985;29:240-242.
in
2. Coleman DL, McPhee SJ, Ross TF, Naughton JL. Secondary syphilis with pulmonary involvement. West J Med 1983; i38:875-878.
3. Schibli H, Harms M. Tumor like pulmonary lesion in secondary syphilis-a case report. Br J Venereal Dis 1961;57:367-371. 4. Quinn TC, Lukehart SA, Goode11 S, Mkrtichian E, et al. Rectal mass caused by treponema pallidum : confirmation by immunofluorescent staining. Gastroenterology 1982;82:135-139. 5. Biro L, Hill AC, Kuflik EG. Secondary syphilis with unusual clinical and laboratory findings. JAMA 1966;206:669-691. 6. Kurumaji Y, Katoh T, Ohtaki N, Tachibana S, Hashimoto K. A case of secondary syphilis with a solitary pulmonary lesion. Dermatologica 1967;174:23-27. Impens N, Warson F, Roels P, Schandvyl W. A rare cause of pleurisy. Eur J Respir Dis 1966;66:366-369. Hartung A, Freedman J. Pulmonary syphilis, a report of three cases of acquired lung syphilis in adults with particular reference to roentgen aspects. JAMA 1932;96:1969-1972. Faris MR, Perry JJ, Westermeier TG, Redmond J. Rectal syphilis mimicking histiocytic lymphoma. Am J Clin Path01 1983; 80:7i9-721.
IMAGING
1992;16:125-128
125
SOLITARY PULMONARY NODULE IN SECONDARY SYPHILIS JOHN V. CHOLANKERIL, MD, FACR, ALAN-LIN GREENBERG, MD, HUSSEIN M. MATARI, MICHELLE R. REISNER, MD AND ABRAHAM OBUCHOWSKI, MD A case of secondary syphilis with a solitary right upper-lobe nodule is presented. Patient presented without any pulmonary complaints or findings. This mass disappeared with residual scar after a full course of penicillin therapy. Our report is the first in the literature that reports a solitary nodule in the upper lobes in secondary syphilis. Previous reports showed nodules only in lower lobes. Our patient also presented with a rectal mass that disappeared on antisyphilitic therapy.
MD,
for which there may be two reasons: 1) these lesions are rare in secondary syphilis; and 2) pulmonary symptoms may not be recognized because most of these patients are not hospitalized and chest x-rays are not performed (4). We report a case of secondary syphilis with a solitary right upper lobe nodule and a rectal mass. The pulmonary lesion cleared with residual small fibrotic area after a full course of penicillin treatment. The rectal mass also disappeared completely.
KEYWORDS:
Syphilis: Spirochete; Pulmonary nodule; Rectal mass; Lymphocytes; Plasma cells
INTRODUCTION The incidence of syphilis has been rising in the United States, particularly in the homosexual population (1, 2). In 1944, Stokes mentioned three clinical forms of acquired pulmonary syphilis-gumma, diffuse bronchopneumonia, and diffuse fibrosis (3). Congenital pulmonary infiltration (pneumonia alba) is also well known. Pulmonary lesions have most commonly been reported in tertiary syphilis with histology of gumma (3). There have been very few reports of lung involvement in secondary syphilis
From the Department of Radiology (J.V.C., H.M.M., A.O.) and from the Department of Medicine (A-L.G., M.R.R.), Jersey City Medical Center, Jersey City, New Jersey. Address reprint requests to: John V. Cholankeril, MD, FACR, Vice President and Dir. of Radiology, Jersey City Medical Center, 50 Baldwin Avenue, Jersey City, 07304. Received August 1990; revised April 1991; accepted September 1991. 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010 0899-7071192/$5.00
CASE HISTORY A 33-year-old Hispanic man was hospitalized for evaluation of a rectal mass. He had been in good health until 1 month prior to entry, when he noted a generalized rash, and experienced anorexia associated with a 12 lb weight loss. He denied pulmonary symptoms or exposure to tuberculosis. He had multiple heterosexual partners. He was born in Cuba, and had come to the United States about 1 year before admission. During this time he was in and out of jail. He denied any homosexual contact. Physical examination was significant for a generalized symmetric pale-red maculopapular rash that did not involve the palms or soles. Generalized nontender adenopathy was present, and a smooth lobulated lesion was palpated on rectal exam. Chest x-ray and tomograms showed a nodular mass density 3 x 2 cm in the anterior segment of the right lobe without calcification (Figure 1).Barium enema and pelvic computed tomography CT showed a submucosal mass in the proximal rectum (Figures 2 and 3). A rapid plasma reagin (RPR) test was positive with a titer of 1 : 128, and a confirmatory FTA-AB was positive. Sputum cytology and cultures were nega-
126
CHOLANKERIL ET AL.
CLINICAL IMAGING VOL. 16. NO. 2
B FIGURE 1. 3 x 2 cm nodule projecting in the anterior segment of right upper lobe. tive. The liver function tests were elevated. Biopsy of the rectal mass demonstrated chronic inflammatory changes, and a Warthin Starry silver stain revealed spirochete forms consistent with Treponema pallidum. Biopsy of a skin lesion showed plasma cell and histiocytic perivascular infiltration with obliterative endarteritis consistent with secondary syphilis. A diagnosis of secondary syphillis with cutaneous, rectal, and probable pulmonary involvement was made. Several hours after treatment with benzathine penicillin was initiated he experienced a typical Jarisch-Herxheimer reaction. He received a total of two doses of intramuscular benzathine penicillin of 2.4 million units each, 1 week apart. Over the next 6 weeks he experienced complete resolution of all his clinical findings, including disappearance of the pulmonary nodule (Figure 4). DISCUSSION Pulmonary lesions in secondary syphilis are extremely rare. There are only a few case reports in
B FIGURE 2. Barium enema shows submucosal lesion in the rectosigmoid region, without obstruction of the flow of barium.
the literature. Coleman et al. (2) reported a case with bilateral lower lobe infiltrates, Biro et al. reported (5) bilateral nodular infiltrates in the lung bases. Gadske reported two cases (4, 6) one with lace-like pulmonary infiltrates in the chest x-ray; the other revealed bronchopneumonia at autopsy. Impens et al. reported a case (7) of right pleural effusion. Schibli et al. (3) and Geer et al. (1) reported solitary pulmonary nodules in the lung bases. Pulmonary lesions in secondary syphilis can manifest as bilateral bronchopneumonia, bilateral solitary or multiple nodules, pleural effusion, or lymphadenopathy (l-4, 6, 7). When they present as nodules, differential
APRIL-JUNE
PLJLMONARY
1992
FIGURE 3. CT demonstrates thickening of rectal wall.
submucosal
NODULE
IN SECODAKY
SYPHILIS
127
mass lesion with
diagnostic considerations should include infection [tuberculosis fungus, bacterial, viral), primary or secondary lung tumors, sarcoidosis, infarction, hematoma, lymphoma, pseudotumor, Wegners, Septic emboli, Kaposi sarcoma, Collagen disease, bronchiectasis, etc. (6, 3). In the previous reports, lung lesions showed a preference to lung bases as well as unilateral involvement (1, 8). Our case appears to be the first case report in the literature of a solitary nodule in the upper lobe in secondary syphilis. There are few references in the literature in which lung resection was performed because of tumor mass in tertiary syphilis (1). In large autopsy series the incidence ranged from 0.25%-12% with most lung lesions in tertiary syphilis (1). All the lung lesions in secondary syphilis reported in the literature, including ours, with the exception of Kurumaji et al. (6) did not have a lung biopsy. Kurumaji et al. report that their case showed poorly differentiated granuloma similar to epithelioid granuloma seen in the patient’s skin biopsy surrounded by lymphocytes and multinucleated cells (6). Classic examples of histopathology in secondary syphilis are perivascular cell infiltrate with plasma cells and endothelial damage to blood vessels as seen in the skin biopsy of our case. Plasma cell infiltration can be sparse or absent in some cases with very little vascular damage (6). Recently Coleman et al. have proposed certain criteria for diagnosis of pulmonary involvement in secondary syphilis (2): 1) history and physical findings, typical of secondary syphilis; 2) serologic tests positive for secondary syphilis; 3) pulmonary abnormalities seen radiographically with or without
B FIGURE 4. Resolution of right upper lobe nodule residual scarring after penicillin therapy.
with
associated symptoms; 4) exclusion of other pulmonary disease, by serologic tests, sputum smears, cultures, and sputum cytology; 5) therapeutic response of radiologic findings to antisyphilitic therapy. The diagnosis of secondary syphilis in our case is based on the above criteria. The skin biopsy also showed classic findings. After treatment with penicillin the patient recovered completely. The liver dysfunction seen in this case also disappeared. The patient also experienced mild Jarisch-Herxheimer reaction during the course of therapy.
128
CHOLANKERIL ET AL.
Syphilis must also be considered a leading cause of rectal mass in any young patient as homosexuality increased markedly over the past decade (5, 9). In addition, to the condyloma lata of secondary syphilis, anorectal lesions associated with early syphilis may include polyps, smooth lobulated masses, mucosal ulcerations, erythema and friability in the anus and rectum (9). We could be seeing more pulmonary as well as gastrointestinal manifestations in the future and it is important to familiarize the physician with these findings in different stages of syphilis. In a heterosexual male, a ‘rectal mass could represent a neoplasm or an inflammatory process. Neoplasm can be a malignant carcinoma, carcinoid, various forms of lymphoma, various polypoid syndromes such as familial polyposis, Gardners, PentzJeghers, juvenile polyposis and noncolonic malignancies by hematogenous dissemination, lymphatic spread, intraperitoneal seeding to the pouch of Douglas, and direct invasion from prostate and bladder. Inflammatory process such as hyperplastic polyps and diverticular granuloma or abscess formation can also present as a mass.
CLINICAL IMAGING VOL. 16, NO. 2
We acknowledge our appreciation preparation of this manuscript.
to Mercedes
Rodriguez
in the
REFERENCES 1. Geer KL, Warshauer,
secondary
syphilis.
DM, Delany DJ. Pulmonary nodule Australas Radio1 1985;29:240-242.
in
2. Coleman DL, McPhee SJ, Ross TF, Naughton JL. Secondary syphilis with pulmonary involvement. West J Med 1983; i38:875-878.
3. Schibli H, Harms M. Tumor like pulmonary lesion in secondary syphilis-a case report. Br J Venereal Dis 1961;57:367-371. 4. Quinn TC, Lukehart SA, Goode11 S, Mkrtichian E, et al. Rectal mass caused by treponema pallidum : confirmation by immunofluorescent staining. Gastroenterology 1982;82:135-139. 5. Biro L, Hill AC, Kuflik EG. Secondary syphilis with unusual clinical and laboratory findings. JAMA 1966;206:669-691. 6. Kurumaji Y, Katoh T, Ohtaki N, Tachibana S, Hashimoto K. A case of secondary syphilis with a solitary pulmonary lesion. Dermatologica 1967;174:23-27. Impens N, Warson F, Roels P, Schandvyl W. A rare cause of pleurisy. Eur J Respir Dis 1966;66:366-369. Hartung A, Freedman J. Pulmonary syphilis, a report of three cases of acquired lung syphilis in adults with particular reference to roentgen aspects. JAMA 1932;96:1969-1972. Faris MR, Perry JJ, Westermeier TG, Redmond J. Rectal syphilis mimicking histiocytic lymphoma. Am J Clin Path01 1983; 80:7i9-721.