Small Ulcerative Lesions Research Articles

Eosinophilic enteritis requiring differentiation from chronic enteropathy associated with SLCO2A1 gene: A case report

Eosinophilic gastrointestinal disease (EGID) is a disorder characterized by infiltration of eosinophils causing mucosal damage and dysfunction of the gastrointestinal tract. The endoscopic findings of eosinophilic enteritis (EoN), an EGID variant, are nonspecific and occasionally difficult to diagnose. In contrast, chronic enteropathy associated with SLCO2A1 (CEAS) is a chronic persistent small intestinal disorder characterized by endoscopic findings such as multiple oblique and circular ulcers. We report the case of a 10-year-old boy who had suffered abdominal pain and fatigue for the preceding 6 mo. He was referred to our institute for investigation of suspected gastrointestinal bleeding because of severe anemia with hypoproteinemia and positive fecal human hemoglobin. The upper and lower gastrointestinal endoscopic findings were normal; however, double-balloon small bowel endoscopy showed multiple oblique and circular ulcers with discrete margins and mild constriction of the intestinal lumen in the ileum. The findings were highly consistent with CEAS, but urine prostaglandin metabolites were within normal limits, and no previously reported mutations in the SLCO2A1 gene were identified. Histological evaluation demonstrated moderate to severe eosinophilic infiltration localized to the small intestine suggesting a diagnosis of EoN. Clinical remission was maintained with montelukast and a partial elemental diet, but emergent surgery for bowel obstruction due to small intestinal stenosis was performed two years after the initial treatment. EoN should be considered in the differential diagnosis of CEAS-like small intestinal ulcerative lesions and normal urinary prostaglandin metabolite levels.

Hereditary diffuse gastric cancer in a Japanese family with CDH1 mutation three case reports

BackgroundGermline pathogenic variants in the E-cadherin gene CDH1 cause hereditary diffuse gastric cancer (HDGC), which is an autosomal dominant cancer syndrome, accounting for 1–3% of all gastric cancers. HDGC harboring a CDH 1 variant is extremely rare in Japan.MethodIn this study we report the clinical courses of three cases with HDGC from a single Japanese family.ResultsThe proband exhibited advanced and metastatic gastric cancer, and was found to have a previously reported heterozygous frameshift variant in CDH1 (NM_004360.3:c.1009_1010del:p.Ser337Phefs*12). Five at-risk relatives underwent presymptomatic molecular testing after careful genetic counseling, and three were molecularly diagnosed as positive for the variant. Esophagogastroduodenoscopy was performed in these relatives revealing abnormal small pale mucosal patches, small ulcerative lesion and no abnormal findings. Moreover, random and targeted biopsies were compatible with pathological diagnosis of HDGC in the three cases, all of which underwent total prophylactic gastrectomy.ConclusionIt is critical for the assessment and management of HDGC patients to be actively offered a multidisciplinary and familial-oriented approach. Notably, genetic screening in suspected individuals and familial members is a determining piece for a higher detection rate and the identification of clinical relevant mutations in both low and high-incidence gastric cancer countries.

Novel biallelic mutations in the DUOX2 gene underlying very early-onset inflammatory bowel disease: A case report

Genetic variants affecting the function of dual oxidase 2 (DUOX2), the catalytic subunit of membrane-bound enzymes that produce hydrogen peroxide, are associated with very early-onset inflammatory bowel disease (VEO-IBD). We report the case of a 1-year-old boy diagnosed with VEO-IBD after presenting with bloody diarrhea. He had pancolitis and an extensive small intestinal ulcerative lesion at age 4 years. Infliximab treatment was successful but was discontinued due to delayed reaction. At age 7 years, treatment with ustekinumab was started, and remission has been maintained for more than 2 years. Whole-exome sequencing identified compound heterozygous missense DUOX2 variants of unknown significance (p.[R1212H];[F1490Y]). Protein expression in the whole-cell lysate and plasma membrane was lower in F1490Y-DUOX2 than in wild-type (WT)-DUOX2. Hydrogen peroxide generation upon ionomycin stimulation was lower in cells expressing R1212H-DUOX2 and F1490Y-DUOX2 than in those expressing WT-DUOX2. The novel, inherited, biallelic DUOX2 mutations may be molecular risk factors of VEO-IBD.

Comment "Asymptomatic small intestinal ulcerative lesions: Obesity and Helicobacter pylori are likely to be risk factors".

There are many causes of anemia. It is unreasonable to simply associate anemia with asymptomatic ulcers in the small intestine.

Indocyanine green fluorescent image-guided inguinal sentinel lymph node biopsy in vulvar cancer.

ObjectiveTo demonstrate near-infrared fluorescence image-guided inguinal sentinel lymph node (SLN) biopsy in patients with vulvar cancer.MethodsA 40-year-old woman with a 3-cm-sized palpable left vulvar mass was diagnosed with vulvar cancer on biopsy with protrusion into the vaginal cavity. Pelvic contrast-enhanced magnetic resonance imaging and F-18 fluorodeoxyglucose positron-emission tomography-computed tomography showed a small ulcerative enhancing lesion confined to the left vulva without distant metastasis. The patient was scheduled for radical vulvectomy with a left inguinal SLN biopsy. Indocyanine green was injected directly into the vulvar mass to map lymphatic drainage. A 4-cm-sized linear incision was made on the left inguinal crease, and the lymphatic channels of the left inguinal area were dissected under fluorescent image guidance using a 1588 Advanced Imaging Modalities Platform laparoscopic camera (Stryker, Kalamazoo, MI, USA).ResultsFluorescence image-guided left inguinal SLN biopsy and radical vulvectomy were performed. The pathologic diagnosis confirmed vulvar adenoid cystic carcinoma with metastasis to the left inguinal lymph node (International Federation of Gynecology and Obstetrics stage IIIA). The patient was discharged without complications and received adjuvant radiotherapy.ConclusionThis video demonstrates a successful ICG fluorescence image-guided left inguinal SLN biopsy in a vulvar cancer patient using a laparoscopic camera. Mapping of inguinal SLNs in patients with vulvar cancer may help in retaining surgical radicality while minimizing operative complications.

The diagnostic dilemma of the most common malignancy in orofacial region involving maxillary tuberocity: A case report

Oral squamous cell carcinoma (OSCC) is the most common malignancy affecting the oral cavity. OSCC presents diverse clinical features including small ulcerative lesion to a large growth. The treatment modality of OSCC depends upon the severity, progress and spread of the disease. The purpose of this case report is to emphasize the etiological factors, clinical features as well as the management protocols of OSCC.

Characteristics and Endoscopic Classification of Ulcerative Lesions Affecting the Ileocecal Valve

Objectives: The aim of this study was to propose an endoscopic classification system for ulcerative lesions on the ileocecal valve and investigate its relevance to the underlying etiology. Methods: Among the 60,325 patients who underwent colonoscopy at our hospital from January 2006 to December 2018, patients with ulcerative lesions on the ileocecal valve were included. The following data were obtained using the hospital’s medical records: sex, age, clinical diagnosis, laboratory data, and endoscopic and histological findings. Patients who have ulcerative colitis and who were not evaluated by histological examination were excluded. Ulcerative lesions on the ileocecal valve were classified into 3 groups according to their endoscopic appearance: small shallow ulcerative lesions without edematous change (group A), lateral spreading shallow ulcerative lesions with edematous change (group B), and deep deformed ulcerative lesions (group C). The association between this endoscopic classification and its clinical diagnosis, clinical course, and the interobserver reliability were evaluated. Results: Of 72 patients who were eligible for analysis, 18 were assigned to group A, 9 to group B, and 45 to group C. Infectious enteritis was mainly assigned to group A (group A, 12; group B, none; and group C, 6; p < 0.0001), inflammatory bowel disease was mainly assigned to group C (group A, none; group B, 5; and group C, 35; p < 0.0001), and malignant tumor was assigned to group C only. Interobserver reliability was extremely high among the 3 examining doctors (kappa value 0.7–0.8). Conclusion: Endoscopic classification was divided into 3 groups for ulcerative lesions on the ileocecal valve, and this system could be beneficial for presuming their clinical diagnoses.

A Review of Making the Modern Diagnosis of Gastrointestinal Reflux Disease: the Lyon Consensus

Various etiologies and diseases may be related to erosions and/or small ulcers without gross inflammatory changes in the surrounding mucosa found in the colon and terminal ileum during colonoscopy. However, studies on follow-up of these lesions are rare. Thus, we investigated the clinical significance of these lesions and their characteristics helpful for differential diagnosis.We reviewed the data of 183 patients with colonoscopically observed erosive or small ulcerative lesions (<2 cm), and analyzed them according to the location, number, and size of lesions, histopathologic findings, chief complaints, laboratory findings, changes of symptoms, and changes in lesions during 4-12 week follow-up period.Histopathologic findings of these lesions included acute nonspecific inflammation, chronic nonspecific inflammation, Crohn's disease, tuberculous colitis, ischemic colitis, Behcet's disease, cytomegalovirus infection, eosinophilic colitis, ulcerative colitis or pseudomembranous colitis, but most of them were nonspecific (84%). In patients with nonspecific inflammation, histopathologic findings, symptoms, location and multiplicity of the lesions were not prognostic factors for the persistency of symptoms and lesions during follow-up period. Two patients with acute inflammation, who showed no improvement in symptoms and lesions, were later diagnosed as Crohn's disease.Erosive or small ulcerative lesions without macroscopic inflammatory changes in the surrounding mucosa during colonoscopy, are mainly nonspecific. However, careful follow-up is required when the symptoms and/or lesions are not improved.

Etiology and long-term rebleeding of endoscopic ulcerative lesions in the small bowel in patients with obscure gastrointestinal bleeding: A multicenter cohort study.

Among patients with obscure gastrointestinal bleeding (OGIB), endoscopic ulcerative lesions in the small bowel have diverse etiologies and often cause rebleeding. Certain characteristics of patients or ulcerations may be reasonable indications for diagnostic balloon-assisted endoscopy (BAE) to assess etiology and may be risks of rebleeding; however, these characteristics are unclear. We aimed to elucidate appropriate indications for diagnostic BAE and predictors of long-term rebleeding in patients with small bowel ulcerative lesions. We conducted a multicenter retrospective cohort study of 68 patients with OGIB, in whom small bowel ulcerative lesions were detected by capsule endoscopy (n=60) and/or BAE (n=43). Patients' characteristics, including medications and endoscopic findings, were evaluated. Predictors of the need for diagnostic BAE to determine ulceration etiology were identified by logistic regression analysis. Rebleeding risks were evaluated using Cox proportional hazards analysis. Single ulcerations were diagnosed in 26 patients, and multiple ulcerations were diagnosed in 42 patients. Among 43 patients who underwent BAE, ulceration etiology was identified in 12 (28%) patients. In the etiology identification, BAE was more useful for a single ulceration than for multiple ulcerations (P<0.001). Among the 68 patients, rebleeding occurred in 14 (21%) patients during a mean follow-up period of 17months. Aspirin use and multiple ulcerations were significant predictors of rebleeding (P<0.05). When we manage small bowel ulcerative lesions in OGIB patients, a single ulceration is a reasonable indication for the diagnostic BAE. The rebleeding rate was lower for single ulcerations than for multiple ulcerations.

Usefulness of virtual chromoendoscopy in the evaluation of subtle small bowel ulcerative lesions by endoscopists with no experience in videocapsule.

Background and study aims: In videocapsule endoscopy examination (VCE), subtle variations in mucosal hue or pattern such as those seen in ulcerations can be difficult to detect, depending on the experience of the reader. Our aim was to test whether virtual chromoendoscopy (VC) techniques, designed to enhance the contrast between the lesion and the normal mucosa, could improve the characterization of ulcerative mucosal lesions. Patients and methods: Fifteen trainees or young gastroenterologists with no experience in VCE were randomly assigned to evaluate 250 true ulcerative and 100 false ulcerative, difficult-to-interpret small bowel lesions, initially as white light images (WLI) and then, in a second round, with the addition of one VC setting or again as WLI, labeling them as real lesions or artifacts. Results: On the overall image evaluation, an improvement in lesion characterization was observed by adding any chromoendoscopy setting, especially Blue mode and FICE 1, with increases in accuracy of 13 % [95 %CI 0.8, 25.3] and 7.1 % [95 %CI – 17.0, 31.3], respectively. However, when only false ulcerative images were considered, with the same presets (Blue mode and FICE 1), there was a loss in accuracy of 10.7 % [95 %CI – 10.9, 32.3] and 7.3 % [95 %CI – 1.3, 16.0], respectively. The interobserver agreement was poor for both readings. Conclusions: VC helps beginner VCE readers correctly categorize difficult-to-interpret small bowel mucosal ulcerative lesions. However, false lesions tend to be misinterpreted as true ulcerative with the same presets. Therefore care is advised in using VC especially under poor bowel preparation.

The Incidence and the Risk Factors of Bowel Perforation Due to Chemotherapy in Gastrointestinal Diffuse Large B Cell Lymphoma

BACKGROUNDBowel perforation after chemotherapy is a serious life-threatening complication of diffuse large B cell lymphoma (DLBCL) involving gastrointestinal tract. R Vaidya et al reported that 9 % of patients with gastrointestinal lymphoma developed a perforation, of which 55% occurred after chemotherapy, and DLBCL was the most common lymphoma associated with perforation (R Vaidya et al Ann Oncol 2013). We assume that the dose reduction of chemotherapy may have advantages to reduce the risk of gastrointestinal perforation and shorten the duration of neutropenia. This study aimed to investigate the incidence of gastrointestinal perforation after chemotherapy, whether reduced dose intensity chemotherapy could reduce the risk of the bowel perforation and how therapeutic modalities influence on the prognosis. PATIENTS AND METHODSWe retrospectively reviewed the medical records of 348 consecutive patients who were diagnosed as having DLBCL at the Gifu University Hospital between August 2004 and April 2015. Eighty-six patients (86/348, 24.7%) were identified to have gastrointestinal involvement of DLBCL by biopsy. The prognosis of DLBCL patients with GI involvement was retrospectively investigated regarding treatments. RESULTSThe involved sites were gastric (51 patients, 48.1%), duodenal (7 patients, 6.6%), colorectal (6 patients, 5.7%), small intestine (36 patients, 34.0%) with duplicate counts permitted. Fourteen patients (14/86, 16.3%) were provided surgical treatment prior to chemotherapy since many of them had already suffered from serious complications such as ileus, perforation and bleeding. Sixty-five patients (65/86, 75.5%) received R-CHOP or CHOP like regimen ± radiation therapy as a first-line chemotherapy. As for remaining patients, two patients received R-hyperCVAD regimen because their histology were Burkitt like, and another patients received Rituximab ± other low dose chemotherapy for their frailness. The 45 patients (45/65, 69.2%) of them received reduced dose intensity (RDI) chemotherapy at the first course because increased risk of gastrointestinal perforation with chemotherapy was concerned about by endoscopic findings. The reduction rates of chemotherapy determined by the attending physician were approximately from 10% to 50%. Six patients (6/65, 9.23%) developed gastrointestinal perforation after chemotherapy (stomach 1, duodenum 0, small intestine 5, colon 0). Three of them received full dose chemotherapy at the time of small intestinal perforation including 2 patients who developed grade 4 neutropenia after the perforation. One of them died of infection after the perforation. The perforation rate was 15.0% in full dose chemotherapy group and 6.67% in the RDI chemotherapy group (p=0.361). The median day of perforation after initiation of chemotherapy was 21 days (range; 5-63 days). The small intestine was the most common site of perforation and 4 patients (4/5, 80%) had the ulcerative type lesions in their perforation site. CONCLUSIONSPrior to chemotherapy, risk of GI perforation should be evaluated. We consider that small intestinal ulcerative lesion is high risk of GI perforation. The RDI chemotherapy may be an optimal therapy for patients with primary GI DLBCL with high risk. Further and larger prospective study should be required to confirm this. DisclosuresNo relevant conflicts of interest to declare.

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding.

To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration (cases) and 60 matched patients with a non-bleeding peptic ulcer (controls) underwent small bowel capsule endoscopy, after a negative colonoscopy (compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowel lesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy. Forty (67%) cases and 18 (30%) controls presented small bowel erosions (P = 0.0001), while 22 (37%) cases and 4 (8%) controls presented small bowel ulcers (P < 0.0001). Among non-steroidal anti-inflammatory drug (NSAID) consumers, 39 (95%) cases and 17 (33%) controls presented small bowel erosions (P < 0.0001), while 22 (55%) cases and 4 (10%) controls presented small bowel ulcers (P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3 (SD = 1.4) g/dL in cases with small bowel ulcerative lesions and 10.5 (SD = 1.3) g/dL in those without (P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6 (27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective (relative risk 0.13, P = 0.05). Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.

When Crohn′s disease is in remission, more patients complete capsule endoscopy study but less lesions are identified

Background and Aims:Wireless capsule endoscopy (WCE) is used in Crohn's disease (CD) to define disease extent. We aimed to define WCE detection rate of small bowel ulcerative lesions and completion rate in CD patients.Patients and Methods:A total of 102 consecutive CD patients, who successfully passed patency capsule, were matched to 102 controls. WCE was performed in both patients (in acute phase and CD clinical remission) and controls.Results:Eighty-six (84%) controls versus 62 (61%) patients in the acute phase (P = 0.003) and 96 (94%) in remission (P = 0.02) completed WCE study. Gastric passing time was 48 ± 66 min in controls, 66 ± 82 min in CD acute phase (P = 0.03) and 30 ± 21 min in remission (P = 0.07). Small bowel passing time was 276 ± 78 min in controls, 299 ± 78 min in the acute phase of CD (P = 0.04) and 248 ± 89 min in remission (P = 0.01). Mean capsule endoscopy Crohn's disease activity index (CECDAI) score was 14 ± 6 in acute small bowel CD, 12 ± 7 in acute small-large bowel CD (P = 0.08) and 2 ± 2 in both CD types while in remission (P = 1.00). Small bowel ulcerative lesions in the acute phase were more frequently in distal small bowel. Aphthous ulcers were frequent a month after entering clinical remission and tend to disappear gradually later on. No ulcerative lesions were present in deep remission. Patency capsule is rather safe to exclude small bowel obstruction.Conclusions:(1) A high percentage of patients with active CD do not complete small bowel study with WCE. (2) Small bowel ulcerative lesions in clinical remission were less severe, although at least 6 months are needed in order for them to disappear.

A Case of Small Bowel Ulcer Associated withHelicobacter pylori

The etiology of peptic ulcer disease in children may be primary, associated with Helicobacter pylori infection, or secondary, relied on underlying disease. Ulcerative lesions by H. pylori are mainly distributed in the duodenal bulb and they are rare below the ampulla of Vater because H. pylori growth is inhibited by bile juice. In this reason, there are only some restrictive reports presented small bowel ulcer associated H. pylori. We found multiple small bowel ulcerative lesions associated with H. pylori in an 11-year-old girl without any systemic disease while performing esophagogastroenteroscopy to the level of the proximal jejunum for differentiating bezoar. The abdominal pain improved after the patient was administered H. pylori eradication therapy. Because a small bowel ulcer associated with H. pylori has rarely been reported, we report it here with literature review.

Vesicular cutaneous lupus erythematosus in a Border Collie in New Zealand

A 3-year-old Border Collie was initially presented for a small ulcerative lesion on the left axilla. The lesion failed to respond to conservative treatment with antibiotics, and the dog was re-presented one week later with ulcerative lesions involving the inguinal and axillary areas bilaterally. Histology of a biopsy of these lesions revealed a lymphocytic ulcerative interface dermatitis. Apoptosis and degeneration of basaloid cells was evident, with clefting along the dermo–epidermal junction. Vesicular cutaneous lupus erythematosus was diagnosed. The dog was treated with prednisone and azathioprine, resulting in complete remission of signs. However, recurrence occurred when drugs were tapered, necessitating ongoing treatment. Vesicular cutaneous lupus erythematosus has been described in North America in Rough-coated Collies and Shetland Sheepdogs. However, in Australasia, it is most commonly observed in Border Collies.

Su1579 Clinical Significance of Erosive and/or Small Ulcerative Lesions in the Terminal Ileum During Colonoscopy

Su1579 Clinical Significance of Erosive and/or Small Ulcerative Lesions in the Terminal Ileum During Colonoscopy

Colonoscopic differences of erosive and/or small ulcerative lesions for diagnosis of colonic inflammatory diseases

Various etiologies and diseases may be related to erosive and/or small ulcerative lesions without gross appearance in the colon during colonoscopy. However, few investigators report on differential diagnosis of colonic inflammatory diseases. Thus, we investigated the clinical significance of these lesions and the value of colonoscopy in the differential diagnosis of colitis. In 110 patients with erosive and/or small ulcerative lesions (<5 mm) who were treated in our hospital during the past 9 years, we retrospectively investigated the relationship between endoscopic morphology and clinical diagnosis. The intestinal lesions were endoscopically classified into three groups (A, hyperemic type; B, aphthous type; and C, verrucous type). The lesions were mainly located in the rectum to the sigmoid colon in group A. In group C, the lesions were most frequently located in the transverse colon and deeper areas. Endoscopically, the etiology was unclear in 74.5% of group A and 73.8% of group B, however, in group C, most of them (81.0%) were associated with specific diseases. With respect to inflammatory bowel diseases, 71.4% of the patients with Crohn's disease and all patients with ulcerative colitis were assigned to group A or B. Erosive and/or small ulcerative lesions belonging to group A or B were mainly non-specific. However, careful follow up was required in groups A and B, which included the possibility of inflammatory bowel diseases, when the symptoms or lesions were not improved.

Enteroscopy-guided Contrast Radiography of Small Bowel Lesions

Purpose: To introduce the method of enteroscopy-guided contrast radiography (ECR) and evaluate the diagnostic value of ECR for those patients with small bowel lesions. Materials and Methods: From Aug 2004 to Dec 2005, 43 double-balloon enteroscopy (DBE) examinations were performed in 32 patients with suspected small bowel diseases. Among them, DBE revealed abnormal finding in 24 patients, and ECR was then performed in 13 of these 24 patients. Results: ECR demonstrated abnormal findings in 11 among the 13 patients. In the cases of tumors and bezoar, the ECR images were very helpful for the surgical planning. However, for the evaluation of inflammatory lesions, DBE showed more accurate results and ECR could not demonstrate small or shallow ulcerative lesions. Conclusion: ECR can be helpful for surgical planning or determination of treatment effect in the cases of small bowel lesions that require surgical treatment or follow-up study.

Child Abuse in Saudi Arabia: Report of Ten Cases

Ten abused children under five years of age (four males, six females) were seen in King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1989G and 1992G. Two children died, five had serious injuries and three had moderately severe injuries. In one of the fatalities, the diagnosis was not suspected until four years after death, when her sister was diagnosed as a case of child abuse. Six children suffered varying degrees of physical neglect and abuse and sexual abuse. The remaining four children had Munchausen syndrome by proxy. Parentally induced illness should therefore be considered in the differential diagnosis of unusual illness with bizarre features, even if the parents' behavior appears normal.

第１期へん桃梅毒例

A 23-year-old male visited our department because of the right cervical node in the submandibular region. There was a 5 X 3 cm, elastic hard lymph node, which had limited mobility and was non-tender. On examination of the mouth, only the right tonsil was swollen, and its entire surface was smooth and marked by erythema. A tumor of the tonsil, such as malignant lymphoma, was suspected.At his second visit small ulcerative lesions were noted on the right tonsil. A more detailed medical history revealed that he had had oral sexual contact within the previous three weeks. Serological tests for sexually transmitted diseases (STD) were ordered and primary syphilis of the tonsil was diagnosed. He was administered bacampicillin (BAPC) for 5 weeks, the swelling of his cervical nodes and the right tonsil was reduced.As sexual activities have become diversified and oro-genital activity has become more common, the tonsils and the pharynx must be examined primary lesions of STD such as syphilis, gonorrhea, chlamydial infection and AIDS.