Esophageal and Oropharyngeal Syphilis in a Newly Diagnosed HIV Positive Patient: Presidential Poster

Abstract

Purpose: Gastric manifestations of syphilis are a relatively rare complication. Diagnosis is often difficult due to non-specific symptoms and findings on radiologic, endoscopic, or histological testing. We present a case of biopsy proven gastric syphilis (GS) with oral and esophageal involvement within the context of a new diagnosis of HIV. A 30-year-old previously healthy male presented with a 10-week history of dysphagia, epigastric discomfort, early satiety, and unintentional weight loss of 25 lbs. He had previously failed therapy with a proton pump inhibitor. Physical exam was remarkable for a well demarcated, hyperpigmented, scaly, diffuse rash in patches across his trunk, back, and extremities, with desquamation of his hands and feet and cervical lymphadenopathy. Initial laboratory data showed mild leukopenia, and a CT scan of the abdomen was unrevealing. Serological testing was significant for a positive HIV test and an RPR titer >1:512 with positive FTA confirmation. He underwent further evaluation with an EGD which revealed oral, esophageal, and antral gastric ulcers with thickened gastric folds. Biopsies of the esophageal and gastric lesions illustrated acute and chronic inflammation with a plasma cell predominance. In light of an elevated RPR titer, an immunohistochemical stain was performed which confirmed GS with a predominant treponemal infiltration (see picture). Subsequently, a lumbar puncture was performed which revealed CSF reactive for VDRL confirming neurosyphilis, albeit asymptomatic. After completing a 14-day course of intravenous penicillin G 24 million units his symptoms and rash resolved. Syphilis with gastrointestinal tract involvement is an extremely rare presentation of the disease. Interestingly, though GS has been reported previously, our case is unique because there have been no reports to date of esophageal involvement and only rare reports with HIV co-infection. Presentation with gastric involvement may indicate advanced disease. Although treatment should be stage-specific, an aggressive approach may be warranted with persistently high titers or symptoms, especially in HIV-infected individuals.Figure