Déjà vu in the catacombs: skull syphilitic osteitis

Abstract

Skull syphilitic lesions, such as those evident on the 16–17th century skull in the fi gure (arrows; fi gure A), might be more familiar to archaeologists than to physicians. Although such syphilitic lesions have not been described for decades, they have made a reappearance in patients with HIV infection. A 41-year-old untreated HIV-positive man (CD4 lymphocyte count 349 cells per μL, viral load 4 log copies per mL) complained of a weeklong headache: a fi rst CT scan was normal (not shown). The pain increased, and he returned 37 days later with infi ltrated nodules of the scalp. A second CT scan and an MRI scan showed large bone lacunae (arrows; fi gure B and fi gure C) and epidural and endocranial infi ltration (arrows; fi gure D and fi gure E). He was diagnosed with syphilis: Treponema pallidum haemagglutination assay (TPHA) was 5120 IU/L and venereal disease research laboratory test (VDRL) was 32 IU/L in serum, with a normal cerebrospinal fl uid analysis. 2 months after 3 weeks’ treatment with ceftriaxone (intravenous, 2 g once daily), MRI scan showed bone reconstruction and a resolution of endocranial infi ltration (arrow; fi gure F). 14 months later, no relapse was noted, and TPHA and VDRL titres had decreased to 180 IU/L and 1 IU/L, respectively. This case demonstrates how syphilis can be rapidly destructive during HIV infection.