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Syphilitic Chancre of the Lips Transmitted by Kissing: A Case Report and Review of the Literature

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Primary syphilic chancre most often involved genitalia, with 12% to 14% extragenital lesions. This article describes a rare case of a female patient with labial ulcer and diagnosed as oral syphilis (OS), an uncommon presentation of primary syphilis. OS is transmitted through orogenital contact. This study is case report and literature review. We report a 27-year-old woman with painless, ulcerative, and indurated lesion on her lower lip and a 7-day history of symmetrically distributed nonpruritic macules. OS was diagnosed based on clinical presentations and serologic test and patient's oral ulcer was cured with intramuscular penicillin G benzathine. However, both the patient and her husband denied any orogenital sexual history before. In addition, her husband was also diagnosed as syphilis later in our clinic. He reported having orogenital contact with other people. Therefore, this is a rare case of OS transmitted through kissing.
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Syphilitic Chancre of the Lips Transmitted by Kissing
A Case Report and Review of the Literature
Xin Yu, MD and Heyi Zheng, MD
Abstract: Primary syphilic chancre most often involved genitalia,
with 12% to 14% extragenital lesions. This article describes a rare case
of a female patient with labial ulcer and diagnosed as oral syphilis (OS),
an uncommon presentation of primary syphilis. OS is transmitted
through orogenital contact.
This study is case report and literature review.
We report a 27-year-old woman with painless, ulcerative, and
indurated lesion on her lower lip and a 7-day history of symmetrically
distributed nonpruritic macules. OS was diagnosed based on clinical
presentations and serologic test and patient’s oral ulcer was cured with
intramuscular penicillin G benzathine. However, both the patient and
her husband denied any orogenital sexual history before. In addition, her
husband was also diagnosed as syphilis later in our clinic. He reported
having orogenital contact with other people.
Therefore, this is a rare case of OS transmitted through kissing.
(Medicine 95(14):e3303)
Abbreviations: OS = oral syphilis, RPR = rapid plasma reagin, STI
= sexually transmitted infection.
INTRODUCTION
Syphilis is a sexually transmitted infection transmitted by
Treponema pallidum subspecies pallidum (TP). Syphilis
remains a major public health problem with increasing inci-
dence worldwide.
1
Primary syphilic chancre most often
involved genitalia, with 12% to 14% extragenital lesions. It
was reported that nonsexual transmission, such as mouth-to-
mouth transfer of prechewed food, can also result in syphilis
infection.
2
In addition, nipple syphilitic chancres have also been
reported after biting by others during sexual intercourse.
3,4
CONSENT
Written informed consent was obtained from the patient’s
parents on behalf of the child for publication of this case report
and any accompanying images. A copy of the written consent is
available for review by the editor of this journal.
CASE REPORT
A previous healthy 27-year-old woman presented with a 6-
week history of a painless, ulcerative lesion with indurated
margin on her lower lip (Figure 1). She also reported a 7-day
history of symmetrically distributed nonpruritic macules on her
trunk and limbs. She denied any history of orogenital sex with
her partner. In addition, her husband also corroborated no
history of orogenital contact. On examination, she had a
22 cm erythematous indurated nodule with ulcer and crust
on her lower lip. In addition, she also had bilateral nontender
submandibular lymphadenopathy. However, no lesion was
observed on her genital and anal areas. She was referred for
a serologic reactive rapid plasma reagin (RPR) test, which was
positive at a titer of 1:128 (normal value: <1:2). A fluorescent
antibody test for T pallidum was positive for both IgG and IgM.
HIV testing was negative. Syphilis was diagnosed, with findings
consistent with both primary (oral chancre and lymphadeno-
pathy) and secondary (macular rash) disease. Therapy with
intramuscular penicillin G benzathine was given. She experi-
enced moderate chills and rigors in the first 24 h after the
treatment with intramuscular penicillin G benzathine, indicat-
ing the reaction of the Jarisch–Herxheimer. The patient
received a weekly dose of penicillin G benzathine for 3 weeks
and returned after treatment. Physical examination revealed that
her oral lesion was significantly reduced.
Her sexual partner was also brought here for fear of an
infection. RPR test was at a titer a 1:64. A fluorescent antibody
test for T pallidum was positive for IgG and negative for IgM.
However, he denied any symptoms associated with syphilis. He
admitted orogenital contact as well as oral contact with multiple
partners. Physical examination including genital and rectal
examination revealed no evidence associated with syphilis.
HIV test was negative. The man was diagnosed as syphilis
and also received treatment with intramuscular penicillin G
benzathine. Both of them denied history of orogenital sex with
each other. The man had a history of multiple oral ulcers before
the onset of his wife’s oral lesion but he did not see the doctor.
His oral ulcer disappeared without any therapy. The woman oral
lesion developed 1 month after his oral lesions. Her syphilis was
considered to transmit through mouth-to-mouth kissing with
another syphilis person.
DISCUSSION
Syphilis is a sexually transmitted disease caused by infec-
tion of T pallidum. Sex contact is the most common way of
transmission. However, studies have showed that nonsexual
transmission, such as mouth-to-mouth transfer of prechewed
food, can also result in syphilis infection.
2
In addition, nipple
syphilitic chancres have been reported after biting by others
during sexual intercourse.
3,4
We report a rare case of acquired
Editor: Jason Leider.
Received: January 11, 2016; revised: February 29, 2016; accepted: March
14, 2016.
From the Department of Dermatology, Peking Union Medical College
Hospital, Chinese Academy of Medical Sciences and Peking Union
Medical College, Beijing, China.
Correspondence: Heyi Zheng, Department of Dermatology, Peking Union
Medical College Hospital, Chinese Academy of Medical Sciences and
Peking Union Medical College, Beijing 100042, China
(e-mail: Zhenghy62@sina.com).
The authors have no funding and conflicts of interest to disclose.
Copyright #2016 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution-NoDerivatives License 4.0, which allows for redistribution,
commercial and non-commercial, as long as it is passed along unchanged
and in whole, with credit to the author.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000003303
Medicine®
CLINICAL CASE REPORT
Medicine Volume 95, Number 14, April 2016 www.md-journal.com |1
primary oral syphilis (OS) chancre after kissing with her
partner, who was infected with syphilis earlier. As far as we
know, this is the first report on infection of primary OS after
kissing another syphilis person.
Primary syphilic chancre most often involved genitalia,
with 12% to 14% extragenital chancre. Oral mucosa is the most
frequent site of extragenital syphilis.
5
Clinical manifestations of
syphilis include several overlapping stages.
6
This patient pre-
sented with a painless ulcerated lesion at the site of inoculation
as well as lymphadenopathy. Serological tests revealed T
pallidum infection. Treatment with penicillin G benzathine
results in the complete resolution of symptoms.
In this case, both the patient and her sexual partner denied
any history of orogenital sexual contacts. And her sexual partner
also came to the clinic and diagnosed syphilis with a history of
multiple oral ulcers before the woman’s symptoms. Oral lesions
are highly infectious, with a reported transmission rate of 18%
to 80% during sexual contact.
7
Thus, the oral chancre of woman
is considered to infect through kissing with her partner, who was
infected syphilis earlier.
From this case report, several clinical and public health
implications can be learned. First, a nonspecific oral ulceration
should remind clinicians of OS since untreated syphilis can
progress to late stage, resulting in cardiovascular and neural
disorders.
8
Diagnosis of OS is based on unprotected orogenital
sexual history, a reasonable incubation period, clinical mani-
festations, and positive serologic tests.
9
In addition, concurrent
HIV infection should be ruled out. Second, kissing can also
transmit syphilis, which may present as an oral chancre. T
pallidum can invade mucous membranes through abrasion.
Therefore, oral chancre can result from kissing with a syphilis
patient. Therefore, kissing with a syphilis patient should also be
avoided in order to block the infection.
REFERENCES
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3. Oh Y, Ahn SY, Hong SP, et al. A case of extragenital chancre on a
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4. Chiu HY, Tsai TF. A crusted plaque on the right nipple. JAMA.
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5. Alam F, Argiriadou AS, Hodgson TA, et al. Primary syphilis remains
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8. Levchik N, Ponomareva M, Surganova V, et al. Criteria for the
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barrier dysfunction. Sex Transm Dis. 2013;40:917–922.
9. Qiao J, Fang H. Syphilitic chancre of the mouth. Can Med Assoc J.
2011;183:2015.
FIGURE 1. Oral chancre and oral lesion after therapy. (A) A
painless, ulcerative lesion with indurated margin on the lower
lip. (B) A remarkably improvement of the oral lesions.
Yu and Zheng Medicine Volume 95, Number 14, April 2016
2|www.md-journal.com Copyright #2016 Wolters Kluwer Health, Inc. All rights reserved.
... T. pallidum can disseminate to nearly all tissues and organs, and T. pallidum DNA has been detected by PCR from a variety of biospecimens, such as lesions, blood, cerebrospinal fluid, urine and semen [5][6][7][8][9]. Recently, several cases provided compelling evidence that mouth-to-mouth transfer of prechewed food, or kissing could also result in the transmission of T. pallidum [10][11][12]. A previous study also showed that there was high prevalence of T. pallidum DNA in oral swabs from patients with syphilis [13]. ...
... However, the high loads of T. pallidum DNA was detected in saliva in syphilis patients in this study suggested that saliva could be an alternative transmission pathway of syphilis. This was not difficult to understand for secondary syphilis, as previous studies have reported that clinical cases of mouth-to-mouth transfer of prechewed food or kissing with secondary syphilis patients have resulted in the infection of T. pallidum [11,12]. Surprisingly, the high loads of T. pallidum DNA in saliva were detected in latent syphilis and symptomatic neurosyphilis (the highest records were 3212 copies/ml and 2728 copies/ml, respectively and much higher than those in the blood). ...
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... contaminated body uids [6][7][8]. In vertical transmission from mother-to-child (CS), following direct contact with the bacterium by the mother, infection spreads to the fetus hematologically, predominantly via the transplacental route [9]. ...
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