Penis and scrotum

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Penis and scrotum

Infectious disorders

Syphilis

Reviewers: Antonio Cubilla, M.D. and Alcides Chaux, M.D. (see Author/Reviewers page)

Revised: 20 May 2010, last major update February 2010

Definition

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● Caused by Treponema pallidum; humans are the only natural host

● Sexually transmitted disease with primary, secondary and tertiary phases (not very infectious in tertiary stage)

Terminology

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● Historically called lues

Epidemiology

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● US incidence dropped thru 2000 but has risen since with more cases in men having sex with men

Etiology

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● Caused by Treponema pallidum, subspecies pallidum, a microaerophilic spirochete that is pathogenic only to humans

Clinical features

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● Called “the great imitator”, because it may mimic other disorders if presentation is unusual

● 30% transmission rate from sexual intercourse

Primary syphilis:

● Painless hard chancre (ulcer with indurated and punched out base) at site of inoculation, often in glans

● Most common affected sites are inner foreskin, coronal sulcus, penile shaft and penile base

● Chancres are usually solitary

Secondary syphilis:

● Bacteremic stage with greatest number of organisms in the body

● Classically has widespread rash (small red macular lesions), including on palms and soles and mucous membranes

● Condyloma lata, formed by soft, flat-topped, moist, red / rose / gray to pale maculopapules, nodules or plaques, is the characteristic anogenital lesion and may become confluent; are common in scrotum

● May have varied clinical presentation

Tertiary syphilis:

● Gummatous form is characteristic: granulomas with epithelioid and giant cells, obliterative endarteritis, necrosis

● Also cardiovascular form and neurosyphilis

● Accelerated time course occurs with HIV infection (1 year to neurosyphilis)

Laboratory

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● Screening tests: rapid plasma reagin (RPR, Wikipedia) and VDRL (Wikipedia)

● Confirmatory tests: fluorescent treponemal antibody-absorption (FTA-ABS) or Treponema pallidum hemagglutination assay

● Note: patients receiving IV immunoglobulin may passively acquire treponemal antibodies (Arch Pathol Lab Med 2002;126:1237)

Case reports

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● 22 year old man with nodular and annular skin lesions over face, back and limbs (Dermatol Online J 2003 Feb;9(1):9)

● 26 year old homosexual man with secondary syphilis localized to penis/scrotum (G Ital Dermatol Venereol 2009;144:725)

Treatment

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● Penicillin G

Clinical images

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Primary chancre

AFIP Fig 10-75: sharply delineated lesion with granulation tissue at base and slightly elevated

borders is present on distal shaft, associated with lymph node enlargement

(courtesy Dr. Chandler, Augusta, GA)

Glans penis has atrophic scar with Secondary rash on palms and soles

condylomata lata at penoscrotal junction

Two well circumscribed, minimally elevated lesions with sharp borders and necrotic centers are present

Micro description (Histopathology)

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● Presence of obliterative endarteritis surrounded by a predominantly plasmocytic infiltrate is characteristic of all stages

● Spirochetes can be identified in primary and secondary lesions but are difficult to demonstrate in gummas

● Primary syphilis: ulceration, granulation tissue and obliterative endarteritis at ulcer base; plasma cells and lymphocytes underlying ulcer, endothelial cell proliferation and capillaritis

● Secondary syphilis: psoriasiform epidermal hyperplasia or spongiform pustular lesions with superficial or deep obliterative endarteritis and lymphoplasmacytic infiltrate at the dermal-epidermal junction; perivascular infiltrate and possible granulomas; also nodal involvement with florid follicular hyperplasia, unusually shaped follicles, endothelial swelling and perivascular cuffs of plasma cells and lymphocytes

● Tertiary syphilis: gummas formed by granulomas with epithelioid and multinucleated giant cells, obliterative endarteritis and necrotic foci

Micro images

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Secondary syphilis: perivascular dermal infiltrate Granuloma

Histologically the lesion is characterized by acanthosis and a dense perivascular lymphoplasmacytic infiltrate in the dermis.

Lymph nodes

Darkfield microscopy

Virtual slides

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Syphilic chancre

Positive stains

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● Spirochete identified by darkfield microscopy, Warthin-Starry stain or Steiner stain

● Treponema pallidum immunostain is more sensitive than Warthin-Starry stain (Hum Pathol 2009;40:624)

Electron microscopy images

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Spirochete in culture

Differential Diagnosis

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● Lymphoma: monoclonal lymphoplasmacytic infiltrate; no clinical or laboratory evidence of syphilis

● Plasma cell myeloma: monoclonal plasma cells, often binucleated; monoclonal gammopathy; no clinical or laboratory evidence of syphilis

Additional references

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● Wikipedia, eMedicine #1; #2

End of Penis and scrotum > Infectious disorders > Syphilis

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