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Laryngeal Syphilis: A Case Report

Article  in  Archives of otolaryngology--head & neck surgery · March 2011

DOI: 10.1001/archoto.2011.16 · Source: PubMed

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 CASE REPORT

Laryngeal syphilis: a case report

Linda Spinato, Georges Verougstraete, Pierre Bisschop

Service d’O.R.L. et de chirurgie cervico-faciale, Centre Hospitalier Universitaire Brugmann, Bruxelles

ABSTRACT
Although the incidence of syphilis has decreased marke d ly with the introduction of antibiotics after the second wo rl d
war, its current incidence is increasing all over the wo rl d, often associated with human immu n o d e ficiency viru s
(HIV) infection.

The authors report the case of a 56-year-old male smoker and drinker presenting with persistent dysphonia. Direct
laryngoscopy revealed features of granulating leukodystrophy on the anterior third of the left vocal cord, highly sug-
gestive of neoplasia. Biopsy showed giant-cell granulomatous laryngitis raising the possibility of several differen-
tial diagnoses. Syphilis serology demonstrated recent syphilis with clinical features of secondary syphilis, despite
the absence of spirochaetes.

Treatment with penicillin G for two weeks allowed restoration of a normal voice and complete resolution of glottal
leukodystrophy.

(Fr ORL-2007;93:358-360)

(Presented on October 2007 at the national congress of the French Society of ORL, Paris)

Submitted for publication: October 2007

Accepted for publication: November 2007
Corresponding author: Spinato Linda
Service d’O.R.L. et de chirurgie cervico-faciale
Centre Hospitalier Universitaire Brugmann
Place A. Van Gehuchten, 4 - 1020 Bruxelles - Belgique
e-mail: lspinato@ulb.ac.be

Fr ORL - 2007 ; 93 : 358

 Laryngeal syphilis
INTRODUCTION
Syphilis is a sex u a l ly transmitted disease caused by
Treponema pallidum whose incidence had decre a s e d
fo l l owing the advent of antibiotics after the second
world war. However, emergence of the human immu-
nodeficiency virus (HIV) has led to a recrudescence of
the number of cases of syphilis and recent reports indi-
cate a growing incidence of syphilis throughout the
world.
During the acute phase (primary and secondary syphi-
lis), the patient essentially presents with mucocutaneous
signs, while various systemic signs may be observed
during the chronic phase (tertiary syphilis).
Syphilis is often said to be a gre at imitator and Sir
William Osler said: “He who knows syphilis, knows
medicine”.
Laryngeal syphilis is rare with polymorphic signs and
remains a diagnosis of exclusion after eliminating car-
cinoma and granulomatous laryngitis.
CASE-REPORT
A 56-ye a r-old man consulted in Feb ru a ry 2007, accom-
panied by his wife, with persistent dysphonia for seve-
ral months.
This patient suffered from hepatitis C and Wernicke-
Korsakoff syndrome secondary to chronic alcoholism.
He had also smoked more than 30 ciga rettes per day fo r
the last 40 years.
D i rect lary n go s c o py revealed gra nu l ating leukody s t ro-
phy of the anterior third of the left vocal cord, highly sug-
ge s t ive of neoplasia, with normal lary n geal mobility.
CT scan of the neck showed a normal periglottic space
and no suspicious cervical lymph nodes.
CT scan of the thorax showed signs of asbestosis.
Panendoscopy was performed and did not reveal any
other suspicious lesions apart from the gra nu l at i n g
lesion of the anterior third of the left vocal cord visua-
lized at the first visit, which was biopsied.
On the day after panendoscopy, the patient developed
a generalized nodulopapular rash sparing the oropha-
ry n geal mucosa. A more detailed clinical history reve a-
led that this was the patient’s second episode of rash,
as the first lesions ap p e a red fo l l owing an episode of
rhinitis one month previously.
359 - Fr ORL - 2007 ; 93
Pat h o l ogical ex a m i n ation of the biopsy specimen
d e m o n s t rated mucosal hyperplasia with deep ep i t h e-
lioid granulomas and signs of vasculitis and necrosis,
in favour of granulomatous laryngitis. Giant cells were
visualized on the surface.
Following a dermatological consultation, a laboratory
wo rk-up was perfo rmed and was normal ap a rt fro m
syphilis serology, which showed positive VDRL/RPR
at 32 units and positive IgG and IgM antibodies, indi-
cating recent infection.
Review of the histology slides did not reveal any spi-
rochaetes.
The patient was treated with penicillin G injections. A
thorough clinical history revealed that this patient was
bisexual and regularly had oral sex with other men.
The patient was reviewed two weeks later with a nor-
mal voice and complete resolution of the glottal leu-
kodystrophy.
DISCUSSION
Syphilis was a frequent sex u a l ly transmitted disease
before the age of antibiotics, particularly penicillin, as
its prevalence during the first half of the 20th century
was 8 to 14% of the general population [1].
Since 1995, there has been a new increase in the inci-
dence of pri m a ry and secondary syphilis, essentially
among homosexual men and sex industry workers [2].
Laryngeal syphilis is rare and presents with polymor-
phic clinical fe at u res. Diffe rential diagnoses include
other forms of granulomatous laryngitis such as laryn-
geal tuberculosis, laryngeal sarcoidosis, or carcinoma,
which was initially suspected in this case.
Laryngeal involvement can be observed at all stages of
the disease, but predominantly in secondary syphilis.
Clinical ex a m i n ation genera l ly reveals a lesion confined
to the epiglottis, its free edge or the aryepiglottic fold [3].
The interesting feature of this case is that the patient pre-
sented lesions exclusively confined to the glottis.
Pat h o l ogical ex a m i n ation of a secondary syphilitic
lesion usually shows a typical granulomatous aspect
associated with multiple spiro chaetes [4]. Although
serology was in favour of recent infection, spirochaetes
were not detected on the biopsy.
 Laryngeal syphilis
Fi g u re 1: Nodulopapular skin
rash
CONCLUSION
Granulomatous laryngitis can be a presenting sign of
syphilis at all stages of infection. Systematic serologi-
cal screening for syphilis should be perfo rmed in all
cases of chronic granulomatous laryngitis in combina-
tion with biopsies to ex clude carcinoma, even in the
absence of spirochaetes.
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Fi g u re 2: Histology of the laryngeal biopsy
REFERENCES
1. Little JW. Syphilis : an updat e. Oral Surg Oral Med,
O ral Pathol, Oral Radiol Endod. 2005;100:3-9.
2. Goh B. Syphilis. Medicine. 2005;10:48-51.
3. Vazel L, Potard G, Boulenger-Vazel A, Nicolas G,
Fo rtun C, Marianowski R. Syphilis lary n g é e. EMC
Oto-rhino-laryngologie. 2004;1:73-77.
4. McNulty JS, Fassett RL. Syphilis: an otolaryngo-
logic perspective. Laryngoscope. 1981;91:889-905.
Fr ORL - 2007 ; 93 : 360