Radiographic Case

IRVING

Findings in Early Acquired Report and Critical Review

EHRLICH AND MORRIE E. KRICUN

Syphilis:

Discussion

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The radiographic and pathophysiologic features of early acquired syphilis are discussed. Bone changes occur in early acquired syphilis and should not be confused with gummas of late syphilis. The radiographic findings are protean and may exist without a clinical history of a cutaneous lesion. The skull, clavicle, and tibia are the sites most frequently involved.

Osseous

syphilis

was

it was not until 1 932 that change in early acquired

first described in 1886 [4], but radiographic evidence of osseous

syphilis was first reported [5, reviewed and added of 10,000
61.

The incidence of radiographically is rare. In 1942, Reynolds and

1 5 cases 1 5 of their reported own. Their 940. between cases Bone case came

diagnosed Wasserman
and from 1 940

bone
[71

disease

1 932

a series have been reported

patients
Introduction from

with
1 91 9-1

early

acquired

syphilis
lesions in a total

over
of 52

a 21 year

period
demoncases,

The
and ture

osseous
have and not

changes
been on

of early
emphasized bone

acquired
in recent disease

syphilis
radiologic We ( 1-3j.

are

rare
litera-

strated including

radiographically the present

textbooks

recently

in 0.1 5%-8.7%

of patients

[5-261. Osseous changes occur with early acquired syphilis [8].

examined during
this disease.

a case of syphilitic the early phase

osteoperiostitis of the secondary

that

occurred stage of
Clinical Features

Bone
primary Case Report dary veloped [7]. The skin

changes
chancre eruption. with the degree

occur
to as late In cutaneous of

as early
several bone soft

as

6 weeks
after bone is swelling,

after
the changes

the
de-

as 14 months cases, destruction eruption

seconsyphilis more

until 4 weeks prior to admission when he noted constant aching pain in the calves with slight muscle weakness and aching and tenderness of the ankles. He noted an eruption on the palms and soles at the time his muscle and joint pain began. There was no history of syphilis

A 35-year-old

black

male

was

well

of secondary usually

severe
ically

than
there

the
may

clinical
be pain,

symptomatology
tissue

[27-29]. symptoms.
secondary and soles.

ClinThe
syphilis It must

tenderness,

headache,

fever,

and

other

constitutional

contact

or treatment

for syphilis.

Physical

examination

showed

a well nourished patient in no acute distress. There were hyperpigmented keratotic macules on the palms and soles bilaterally.

characteristic dermatologic is a maculopapular rash be realized without a that early history of

change of over the palms syphilitic primary

compatible with secondary the pretibial area bilaterally. was unremarkable.

Fluorescent treponemal

syphilis.
The antibody

There

was also swelling

of the was examination positive.

of

remainder absorption

osteomyelitis or secondary

may occur cutaneous

lesions
and
Radio-

and,

in fact,

may

develop

a short
serologic lesions

time
test occur

after
for [5.

blood
syphilis 1 71.

the rapid plasma graphs disclosed

reagin was reactive multiple aggressive

at a 1 :64 osteolytic

dilution.

transfusion may not

[1 6, 20]. Also, the be positive when bone

lesions

in the

cortex of the tibiae, fibulae, ulnae, and radii (figs. 1 and 2) with solid periosteal reaction in several locations. There was minimal destruction of the proximal aspect of the second metacarpal along with solid periosteal reaction (fig. 3). No lesions were present in the skull, clavicles, other long bones, ribs. spine, or feet. Biopsy of the left fibula disclosed necrotic bone with inflammatory cell infiltrate composed mostly of mature plasma cells. The vascularity was prominent and the endothelial cells were swollen and pleomorphic. Spirochetes were identified within the inflammatory cell exudate. The pathologic diagnosis was syphilitic periostitis and osteitis.

Pathophysiology The spirochetemia

dary During syphilis this occur stage,

and mucocutaneous
1 -3 months after may the spirochetes canals, and

lesions
primary

of seconchancre. hema-

be disseminated

togenously
teum, [30]. and canals of bone Several

throughout
investigators by way of and

the body
[25, blood

and

found
space state in

in the
that the

periossyphilis space

Haversian begins to the

medullary 31 , 32]

of all bones

as an osteomyelitis cortex periosteum.

in the vessels

medullary

spreads

Haversian

The patient was treated with 12 million units of procaine penicillin intramuscularly over a 10 day period. During hospitali-

zation, he developed herpes zoster Aadiographs 1 month later showed

of the lesions, but after resolution of the lesions 3 months (fig. 4).

and molluscum

contagiosum.

no change in the appearance there was almost complete

Spirochetes induce a perivascular response followed by muscularis atrophy, endothelial proliferation, and subsequent endarteritis obliterans [17, 30]. These vascular changes are the cause of osteochondritis, periostitis, osteitis, or osteomyelitis depending on which part of the
bone is involved. The vascular changes lead later to secon-

Received March 15, 1976; accepted after revision Department of Diagnostic Radiology, Hahnemann reprint requests to M. E. Kricun. Am J Ro.ntg.nol

June

16. 1976. Medical College

and Hospital.

230

North

Broad

Street,

Philadelphia.

Pennsylvania

19102.

Address

127:789-792.

1976

789

if,

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EARLY

ACQUIRED

SYPHILIS

791

dary
late

ischemia
syphilis [17].

and

caseation

necrosis-the

gumma
.:
.

of
C

2. Greenfield
delphia,

GB: Radiology
Lippincott. 1975

of Bone

Diseases,

2d

ed.

Phila-

Anatomic The skull

Distribution and clavicle, are the syphilis. followed sites Other by the most sites nasal and tibia, humerus, involved with less

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ulna, and radius, in early acquired

frequently reported

frequency
bones palate, knee,

are
of the

the
hands ileum, Features

femur,
and ischium,

fibula,
feet,

sternum,
bones, spine.

ribs,
facial

scapula,
bones,

Radiographic

The response acquired syphilis

host response,

of bone depends
and the

to the spirochete on the virulence

area of bone

attack in early of the organism,

Periostitis,

involved.

osteomyelitis, and osteitis manifested by periosteal reaction, bone destruction, or sclerosis may occur alone or in combination and may be localized or diffuse. Periosteal reaction is usually laminated or solid, but can be perpendicular simulating an osteosarcoma [1 7, 28, 33]. Osteomyelitis causes osteolytic changes in the cortex and medullary space, usually with an aggressive pattern of bone destruction. Skull lesions appear as irregular areas of bone destruction; the outer table is more frequently involved than the diploae and inner table. There may be soft tissue swelling and wavy periosteal reaction [7]. In the long bones sequestration [1 7. 31 ], pathologic fracture [6, 31 , 34], epiphyseal separation [31 ], and even syphilitic arthritis [32] may occur as sequelae. Sequestra in syphilis are difficult to visualize radiographically because they are small and usually occur in cancellous bone [17]. It should be stressed that the destructive lesions in early acquired syphilis are those of osteomyelitis and do not represent gummas.
Differential Diagnosis

3, MUrray RO, Jacobson HG : The Radiology of Skeletal Disorders. Exercises in Diagnosis. Baltimore, Williams & Wilkins, 1971 4. Lancereaux E: Les ost#{233}ites syphilitiques. Ann Dermatol Syphiligr (Paris) 7 :26 1 , 1886 5. Nitchew L: A propos des ost#{233}o-p#{233}riostites syphilitiques pr#{234}coces. Ann Malad Vener 27:600-605, 1932 6. Gougerot MM, Mathieu P. Jais: Fracture spontan#{233}e de Ia clavicule au debut de Ia syphilis secondaire. Ann Ma!ad Vener27:31, 1932 7. Reynolds FW, Wasserman H: Destructive osseous lesions in early syphilis. Arch Intern Med 69:263-276, 1942 8. Bauer MF, Caravati CM: Osteolytic lesions in early syphilis. Br J Vener Dis 43: 1 75-1 77, 1967 9. Bloom P: Destructive osteitis and facial paralysis in secondary syphilis. Arch Dermato! Syph 29:940, 1934 10. Burrows HJ: Pathological fracture of the humerus complicating late secondary syphilis. Br J Surg 24:452, 1937 1 1 . Cabanel G. Phelip X, Gintz B: Ost#{233}ite cranienne lacunaire de Ia syphilis secondaire. Presse Med 79:1755-1756, 1971 1 2. Dillingham FH, McCafferty LK: Bone syphilis. Am J Syph 10:378-382, 1926 13. Exley M. Newton AW: Osseous syphilis. N Eng!J Med 234: 661-664, 1946 1 4. Farina A: Su un caso di osteomielite gummosa nel periodo precoce della lue. G Med Mi! 87:59, 1939 1 5. Lefkovits AM, Cross KR: Bone lesions in early syphilis. Am J Clin Patho! 1 6:693-700, 1946 1 6. Mandelbaum H. Saperstein AN: Transmission of syphilis by blood transfusion: a case of acute gummatous osteomyelitis.JAMA 1 7. Metcalfe 106:1061, JW: Syphilitic 1936 osteoperiostitis-skull, ribs, and

phalanges. 1 8. Newman
during

USN Med Bull 49:528-535, BA, Saunders HC: Skeletal secondary syphilis. NY State
JDJ: Uncommon complications

1949
system manifestations Med J 38:788-795,
of early syphilis.

1938
19. Parker

Hepatitis, periostitis. iritis with papillitis. and meningitis. Br J Vener Dis 48:32-36, 1972 20. Pi#{225}n HC. Frazier CN: Transfusion syphilis with widespread
osteomyelitis and cutaneous lesions of an erythema multi-

Syphilis has long been called the great imitator, and the differential diagnosis of bone changes reflects this statement. Aggressive-appearing osteomyelitis with or without periostitis may simulate pyogenic osteomyelitis, metastatic
disease, histiocytosis, lymphoma, leukemia, tuberculosis,

21 22. 23.

fungal
34-36]. coma

disease,

and

Ewings

sarcoma
may

[7,

1 3, 1 7, 27,
osteogenic

29,
sar-

An osteoperiostitis [17, 28, 33].

simulate

ACKNOWLEDGMENTS Drs.
primary

24. were responsible

We thank

Hugh
care

Bennett
and

and
follow-up

Ronald
of this

Shore
patient.

for
Carol

25. 26.

Garifo

for excellent

secretarial

assistance.

REFER ENCES
1. Edeiken Bone.

J, Hodes PJ: 2d ed. Baltimore,

Roentgen

Diagnosis

of

Diseases

of

27.

Williams

& Wilkins,

1973

forme type. Chin Med J 57:301 , 1940 Squires JB, Weiner AL: Osteitis in early syphilis: report of a case. Arch Dermato! Syph 39:830, 1939 Tauber EB, Goldman L: Syphilitic anemia with diffuse osteitis and superinfection. Am J Syph Neurol 1 9:339, 1935 Thompson AG, Leedham CL, Hailey H: Osteomyelitis of the skull in early syphilis. Report of two cases probably influenced by trauma. Am J Syph Gonn Vener Dis 33:34-42, 1949 Thompson AG. Preston RH : Lesions of the skull in secondary syphilis. Am J Syph Gonn Vener Dis 36:332-341 , 1952 Truog CP: Bone lesions in acquired syphilis. Radiology 40: 1-9, 1943 Wile UJ, Welton DG: Early syphilitic osteomyelitis with a report of two cases. Am J Syph Gonn Vener Dis 24:1-12, 1940 Galvin AH: Syphilis of the osseous system. Am J Syph 12:187-193, 1928

- References 37-48. interested reader.

while

not

cited.

have

been

included

for

the

792

EHRLICH

AND

KRICUN

28. Sante

LA: Radiographic

manifestations

of

syphilitic

diseases

39.

ofbone.AmJSyph

12:510-516,

1928

Bingold AC: 55:354-355, tertiary Holmes

Luetic 1962

lumbar

spondylitis.

Proc

R Soc

Med

29. Ungerman
simulating 229. 1938

AH,

Vicary

WH.
disease.

Eldridge
Am of

WW:

Luetic

malignant

J Roentgenol Disease. South Med

osteitis 40:224-

30. Robbins

SL:
1974 JS. Boyd

Pathologic HB: Bone

Basis syphilis.

Philadelphia, J 29:371
-

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Saunders,

31

Speed 377, 1936 32. Ware MW:

.

Syphilis
Surg

of the bones
46:199-205,

and some
1907

radiographic

findings.

Ann

33. Skapinker
34.

S. Minnaar

D: Syphilitic

disease

of the long bones

HC, Kampmeier RH: The bone lesions in acquired syphilis. South Med J 36:556-559, 1943 41 . GW. Lingley JR: Roentgenologic manifestations of syphilis. N EnglJ Med 217:983-987, 1937 42. Karaharju EO. Hannuksela M: Possible syphilitic spondylitis. Acta Orthop Scand 44:289-295, 1973 43. Nathan AS, Lawson W: Syphilitic osteomyelitis of the mandible. Oral Surg 1 7:284-288, 1964 44. Rost GS: Roentgen manifestations of Bejel (endemic syphilis) as observed in the Euphrates River Valley. Radiology 38:320-325,
45. Roy
syphilis.

40. Francis

in the Bantu. J Bone Joint Surg 33-B:578-583, 1951 Olmstead EG: Gummatous osteomyelitis with pathologic fracture complicating general paresis. Am J Syph 32:243-

1942
Laird SM: Acute
Dis 49:555,

RB,

periostitis

in

early

acquired
syphiClinical bones

250,

1948

35. Carman AD: A review of the roentgenology of syphilis. Am JSyph 2:297-343, 1918 36. Johns D: Syphilitic disorders of the spine. J Bone Joint Surg 52-B:724-731, 1970 37. Alexander U, Schoch AG: Osseous syphilis. Am J Syph Gonn Vener Dis 26:397-406, 1942 38. Bailey GG: Manifestations of bone syphilis. Urol Cut Rev 49:11-12, 1945

1973 46. Stewart DM: Roentgenological manifestations lis. Am J Roentgenol 40:2 1 5-223, 1938 47. Stokes JH, Beerman H, Ingraham NR Jr: Syphilology, 3d ed. Philadelphia, Saunders,
Br J Vener 48. Wile UJ, Senear FE: A study of the Am involvement Sci

in bone Modern

1944
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and joints 1916

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syphilis.

J Med

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