SESSION TITLE: Infectious Disease Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: Pulmonary syphilis must be considered in the differential diagnosis of multiple pulmonary nodules in an immune compromised patient.
CASE PRESENTATION: A 53 year old man presented to his physician for complaints of fever, chills, night sweats, and weight loss. He denied any respiratory symptoms and reported a 35 pack year smoking history. Physical exam revealed that he had oral thrush and palpable lymph nodes in the supraclavicular, cervical, femoral, and axillary lymph node regions. Computed tomography (CT) imaging of his chest revealed a 4 cm necrotic mass in the right middle lobe and innumerable pulmonary nodules in both lungs. Laboratory results revealed that he was human immunodeficiency virus (HIV) positive, Venereal Disease Research Laboratory Test (VDRL) positive, and his rapid plasma regain test (RPR) was reactive with a titer of 1:256. Cervical lymph node biopsy, bronchoscopy, and CT guided biopsy were nondiagnostic. Culture and serum studies to detect bacterial, fungal, and tubercular disease were negative. Accordingly, the patient underwent Video Assisted Thoracic Surgery (VATS) procedure for lung biopsy. Tissue obtained from the VATS exhibited complete effacement of the normal lung histology by a variably cellular, necrotizing and fibrosing process containing a diffuse, dense inflammatory infiltrate composed of a dominant population of a polytypic, kappa and lambda reactive, CD 138 positive plasma cells. During the course of this workup, the patient was treated with three injections of Penicillin G for treponema infection. Three weeks after receiving Penicillin G, CT scan revealed near resolution of the pulmonary nodules.
DISCUSSION: Coleman et al proposed criteria to standardize the diagnosis of pulmonary syphilis. These include history and physical findings typical of secondary syphilis, serologic test results positive for syphilis, pulmonary abnormalities seen on radiographs, exclusion of other forms of pulmonary disease, and therapeutic response to antisyphilitic treatment visible on radiographs. Our patient met all of the criteria for the diagnosis of pulmonary syphilis and his CT scan findings rapidly improved after the administration of penicillin.
CONCLUSIONS: Pulmonary syphilis must be considered in the differential diagnosis of multiple pulmonary nodules in an HIV patient. Our case highlights the dramatic radiographic improvement seen with the treatment of syphilis.
Reference #1: Coleman DL, McPhee SJ, Ross TF, Naughton JL. Secondary syphilis with pulmonary involvement. West J Med. 1983;138:875-878.
DISCLOSURE: The following authors have nothing to disclose: Ariella Reinherz, Peter Kaplan, Allan Smith
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