Chest Infections |

Two Great Mimics in One: A Rare Case of Pulmonary Syphilis and Tuberculosis FREE TO VIEW

Peter Nguyen, MD; Mohita Singh, MD; Veronica Vittone, MD; Yaw Frimpong-Badu, MD; Linda Green, MD
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Baylor College of Medicine, Houston, TX

Chest. 2015;148(4_MeetingAbstracts):92A. doi:10.1378/chest.2270817
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SESSION TITLE: Chest Infections I Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Syphilis is a sexually transmitted disease cause by Treponema pallidum. The disease can affect many organ systems when inadequately treated, but rarely is there pulmonary involvement. We describe an extremely rare case of pulmonary syphillis in a HIV patient who was later discovered to also have active tuberculosis.

CASE PRESENTATION: A 32 year old man with a history of intravenous drug use and HIV (CD4 475) presents with fever, night sweats, productive cough, and pleuritic chest pain for two months. His past medical history is also significant for untreated latent tuberculosis (TB) and treated primary syphyilis with IM benzathine pencillin G one year ago. On physical exam, the patient was afebrile with normal vitals. His labs revealed a serum RPR titer of 1:1. CT of chest demonstrated multiple bilateral nodular opacities with the largest excavated nodule (2.1 cm) located in the left upper lobe. Patient was placed in airborne isolation for concerns of active TB. Intial workup with multiple sputum studies including bacterial, fungal, and AFB smear and culture were negative. Patient underwent bronchoscopy with endobronchial ultrasound for biopsy of the left upper lobe lesion. Microscopic examination of the biopsies revealed fibrinoid necrosis with histiocytes, lymphocytes, numerous plasma cells, and noncaseating epitheloid granulomas. AFB and silver stains were negative. The Warthin-Starry and Steiner stains showed possible treponemes. The biopsy samples were then sent out to perform immunohistochemical (IHC) stains for spirochetes. IHC stains revealed intact spirochetes confirming suspicion of inflammation related to pulmonary syphilis infection. Two weeks later, the patient had worsening symptoms and a repeat sputum AFB was positive for M. tuberculousis. The patient was then treated for both active TB with RIPE and pulmonary syphilis with intravenous penicillin.

DISCUSSION: Pulmonary syphilis is very rare and was first described during the pre-antibiotic era. This was seen in congenital and tertiary syphilis with some reported cases of pulmonary gummas. Since the 1900s, about 10 cases of pulmonary syphilis have been reported, usually in setting of secondary syphilis. Clinical manifestations included fever, productive cough, pleuritic chest pain, night sweats, and nodular pulmonary lesions. In all these cases, the pulmonary lesions resolved with antibiotic treatment.

CONCLUSIONS: In general, HIV patients presenting with pulmonary lesions can be a diagnostic challenge. In our patient, though pathology findings are suggestive of gummas, the cavitary pulmonary lesions are likely cause by tuberculosis.

Reference #1: Gary David, et al. Secondary Pulmonary Syphilis: Report of a Likely Case and Literature Review. Clinical Infectious Disease. 2006; 42: 11-15.

Reference #2: McPhee SJ. Secondary Syphilis: Uncommon Manifestations of a Common Disease. West J Med.1984;140:35-42

DISCLOSURE: The following authors have nothing to disclose: Peter Nguyen, Mohita Singh, Veronica Vittone, Yaw Frimpong-Badu, Linda Green

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