Pressure ulcer‐like presacral gummata in a patient with tertiary syphilis

Abstract

Pressure ulcers are common among elderly patients. Here, we describe a case of tertiary syphilis with ulcerated gummata, appearing as a possible pressure ulcer. In such a case, wound management has to be accompanied by specific antibiosis to achieve healing.

Introduction

Chronic wounds are a challenge of modern medicine. In Western countries, the most common types are leg ulcers of vascular or neuropathic origin and pressure sores. Malignancies and infections, however, should not be forgotten when dealing with recalcitrant chronic wounds.

In individual cases, the presentation of a common disease might have an uncommon cause, as it was the case in the patient presented herein.

Case

An 83‐year‐old male patient was referred to the Department of Dermatology because of chronic presacral ulcer thought to be a pressure ulcer that developed about a month previously. He suffered from arterial hyper‐tension but was not immobile.

On examination, we found a 9 × 5 cm foetid ulcer with elevated border. The ulcer was painless with a dull red border (Figure 1a).

Figure 1.

Presacral ulcer. (A) Pre‐treatment situation, fibrin‐covered inflammatory ulceration. (B) After 2 weeks of systemic antibiosis and topical management with alginate dressing.

Radiological investigations

Skull X‐rays

There were two hypodense cranial lesions with a maximum diameter of 12 mm (frontal bone and left temporal bone). Thoracic and spine X‐rays showed age‐related changes only. Abdominal ultrasound and computer tomography revealed renal cysts and gall bladder stones, no enlarged lymph nodes or tumours.

Electrocardiography showed a sinus frequency without abnormalities.

Laboratory investigations

Laboratory investigations showed the following results: blood sedimentation rate 74 mm/hour; haemoglobin 4·5 mmol/l (normal range: 8·8–12·1 mmol/l); erythrocyte count 2·87 tera particles (=10¹²) (Tpt)/l (normal range: 4·6–6·2 Tpt/l); leucocyte count 2·4 Gpt/l (normal range: 3·8–10·0  biga particles (=10⁹) (Gpt); gammaglobulins 30·9% (normal range: 11–22%); antinuclear antibodies 1:160 (normal: <1:80); veneral disease research laboratories 1:2; trepodema pallidum hemagglutination 1:10 240; fluorescence trepodema antibody‐absorption‐immunoglobulin (Ig)G 1:5; 19‐S‐IgM‐FTA absorption test negative; human immunodeficiency virus (HIV) serology negative.

Bone marrow biopsy revealed a hypoplastic erythropoiesis and myelopoiesis and excluded lymphoma or myelofibrosis.

A skin biopsy was taken from the ulcer. At the ulcer border, the epidermis was hyperplastic. The dermal vessels were ectatic and accompanied by papillary oedema. There was a diffuse mixed infiltrate composed of plasma cells, lymphocytes and histiocytes. Plasma cells expressed both λ‐ and κ‐light chains. Less than 10% of cells expressed CD‐20 characteristic for B‐lymphocytes. Wartin–Sterry silver impregnation failed to demonstrate spirochaetes.

The diagnosis of tertiary syphilis was confirmed, and the patient was treated with high doses of intravenous penicillin. Topical wound treatment was performed with alginate dressings. Following 2 weeks of treatment, the lesions improved, and the patient was discharged with follow‐up in the outpatient clinic (Figure 1b).

Background

Tertiary syphilis is characterised by the development of syphilitic tubercles and gummata. The benign type with gummata has virtually disappeared (1). In the beginning of the last century where no antibiotics were available, these lesions were observed mostly within 4–5 years after infection, with great variety up to 46 years after infection (2). In recent literature, it was noted that most gummatous lesions develop within 15 years after infection (3). Gummatous lesions may affect every organ, but skin, bone and liver are the most common sites of involvement. The cutaneous lesion can be nodular, nodulo‐ulcerative or gummatous as that in the present case and are rarely contagious (4, 5). Gummatous lesions may develop ulcers that heal with scars. Bone lesions are marked by osteitis and periosteal changes with nocturnal pain and swelling (6). The cranial lesions seen in the present case may suggest bone involvement, although this has not been proven.

Presacral ulceration may be caused by a wide range of diseases. In elderly people with immobility, pressure sores are the most common cause. But perianal Crohn's disease (7), lymphogranuloma venereum (8), tuberculosis (9), herpes exulcerans et persistens in immunocompromised patients (10), Behcet's disease (11), ergotism (12), pyoderma gangraenosum (13), Langerhans' cell histiocytosis (14), anal cancer (15) and lymphomas (16) have to be considered in addition.

The different stages of syphilis may also be associated with ulcers in the perianal and presacral region, i.e. primary lesions and secondary syphilis (17). This case developed a progressive presacral ulceration that on histology and syphilis serology could be confirmed as being caused by benign tertiary syphilis. In recent years, rare cases of benign syphilitic gummata have been observed in HIV‐positive patients (1). The present HIV‐negative case demonstrates the need to think of syphilis again in unusual presentations of skin disease independent of the age of patients.

Summary

• • This case illustrates the many facets of systemic infection by Treponema pallidum.
• • It also highlights the need of histological and serological investigations in patients with chronic wounds.