1. Of Tongues and Treponemes Clinical Case Studies from the Denver Metro Health Clinic

2. Case 1

3. Case 1 - History 24 year-old gay man Contact to syphilis (stage unknown) Painless lesion left side tongue noticed 3 days ago Also complains of dysuria and faint rash on trunk and soles of feet Reports insertive and receptive oral (unprotected) and anal (mostly protected) intercourse No history of penile sores

4. Case 1- Physical Exam 2 cm patch left lateral side of tongue Generalized macular rash, including palms and soles Clear discharge from penis

7. Case 1- Lab Results RPR reactive 1:64 FTA reactive 4+ Gram stain urethral discharge >10 wbc/hpf Urine NAAT: chlamydia positive; gonorrhea negative HIV non-reactive

8. Case 1- Diagnosis and Treatment Diagnosis –Secondary syphilis –Mucous patch tongue –Nongonococcal urethritis (chlamydia+) Treatment –LAB 2.4 MU –Doxycycline 100 mg BID / 7 days

9. Case 1 – Follow Up Patients was seen 6 months later complaining of dysuria and urethral discharge Diagnosed with urethral gonorrhea and treated with ciprofloxacin and doxycycline (case was prior to 2005) RPR at f/u: reactive 1:8 All lesions cleared HIV non-reactive No further follow-up

10. Case 2

11. Case 2 - History 41- year old HIV-negative gay man Lesion right lateral side of tongue since 4 weeks Reports 3 sex partners in past 3 months Unprotected oral sex only

12. Case 2 - History Syphilis history –13 months prior: similar lesion in conjunction with penile lesions –Diagnosed with early latent syphilis –Treated with LAB 2.4 MU –RPR reactive 1:128; declined to 1:8 after 7 months

13. Case 2 – Physical Exam 1.5 cm patch right lateral side tongue with central ulceration Right-sided lymphadenopathy neck No rashes or other ulcerations Warts penis

14. Case 2, at first presentation

15. Case 2 – Lab Results RPR reactive 1:64 GC urethral, pharyngeal, rectal: negative CT urethral negative HIV non-reactive

16. Case 2 Discussion –Is lesion on tongue a chancre or mucous patch? Diagnosis –Primary vs. secondary syphilis Treatment –LAB 2.4 MU Follow-up –Lesion cleared after 1 week

17. Case 2, 7 days after LAB treatment

18. Note Darkfield microscopy is not recommended in the evaluation of oral lesions as other treponemes (especially T. denticola, associated with periodontal disease) are indistinguishable from T. pallidum.

19. Disclaimer Copyright all clinical photos: –Dr. Kees Rietmeijer, STD Control Program, Denver Public Health Department Individual slides can be used for educational purposes with reference to source and/or inclusion of the DMHC logo