Tongue Ulcers

A case of a 38yom with hx HIV (CD4 234, ran out of ART 1 month prior) presented with 2 weeks of a painful ulceration on his tongue and painful bilateral neck swelling (lymphadenopathy with necrotic nodes on CT). The differential diagnosis for oropharyngeal ulcerations was discussed as well as how to diagnose and treat syphilis as this turned out to be a case of primary syphilis of the tongue. Significantly, his sexual history was not elicited until day 2 of his hospital stay.

Oral lesions: tumors (SCC, melanoma, Kaposi, lymphoma), infections (HSV, VZV, CMV, coxsackie, HIV, candidiasis/other fungal, MAI, syphilis), other (aphthous, Behcet’s, SLE, pemphigoid/gus, SJS/EM)

Syphilis: two-stage diagnosis

  • Non-treponemal screen (serum reactivity to cardiolipin antigen) – RPR, VRDL, TRUST – many false positives, titers should decrease with treatment
  • Treponemal confirmation (antibodies to treponemal antigens) – FTA-ABS, TP-EIA, TP-PA – will stay positive for life after infection

Syphilis: treatment depends on natural history – pencillin still the mainstay of treatment – one or 3 doses weekly IM of penicillin benzanthine, or continuous penicillin IV for neurosyphilis

  • Primary: 3-90days post inoculation painless chancre (can be painful if secondarily infected) teeming with spirochetes (only visible under dark field microscopy), draining lymphadenopathy (one dose)
  • Secondary: week-months fever, headache, rash (maculopapular, mucosal, palms/soles), lymphadenopathy, condyloma lata (one dose)
  • Tertiary: years – neurosyphilis requires pencillin IV for 14 days, others are 3 doses over 3 weeks
    • CNS: meningitis, declining cognition, paresis, tabes dorsalis, blindness, deafness
    • CV: aortitis
    • Gumma (skin/bone)
  • Latent: asymptomatic (early < 1 year, late > 1 year): 3 doses over 3 weeks
  • Jarisch-Herxheimer Reaction: 1-3 hours after first dose of antibiotics patient may develop fever, rigors due to massive release of spirochete proteins