
==== Front
IDCases
IDCases
IDCases
2214-2509
Elsevier

S2214-2509(24)00137-9
10.1016/j.idcr.2024.e02061
e02061
Case Report
Syphilitic uvula ulcer
Shibutani Koko kokoshib@luke.ac.jp
⁎
Mori Nobuyoshi morinob@luke.ac.jp

Division of Infectious Diseases, St. Luke’s International Hospital, Tokyo, Japan
⁎ Correspondence to: 9-1 Akashi-Chuo, Chuo-ku, Tokyo 104-8560, Japan. kokoshib@luke.ac.jp
17 8 2024
2024
17 8 2024
37 e0206111 4 2024
27 6 2024
16 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
A 42-year-old sexually active man with HIV on ART (antiretroviral therapy) who has a history of syphilis presented with fever and severe sore throat for which he could not eat or drink. He admitted to high-risk sexual intercourse with multiple partners 10 days prior. Physical examination revealed an injected throat and uvula ulcer. PCR for Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum and Ureaplasma parvum from pharynx and rapid group A streptococci test were negative. No significant bacteria were grown from the throat swab culture. The RPR (rapid plasma reagin) titer, which had previously been negative, increased to 1:2. From these results, uvula ulcer was thought to be caused by primary syphilis. He was treated with one shot of benzylpenicillin 2.4 million units intramuscularly, and his ulcer completely disappeared in seven days.

Keywords

Syphilis
Sexually transmitted infections
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pmcBackground

Sexually transmitted infections (STIs) are a major public health problem in both resource-rich and limited countries. In Japan, the increase in the number of syphilis cases is particularly significant [1].　Because STIs can lead to various complications, managing and controlling sexually transmitted infections is important, especially among people living with HIV (PLWH). However, the most common cause of pharyngitis is respiratory viruses and group A streptococci, it is important to recognize that sexually transmitted infections are a differential diagnosis for pharyngitis as well as genital infections for urethritis, especially in those who have oral sex [2,3]. In addition to these sexually transmitted infections, syphilis is also known to cause pharyngitis [4].

Case report

A 42-year-old sexually active man with a well-controlled HIV infection treated with tenofovir-alafenamide/emtricitabine and dolutegravir presented with a fever of up to 39 degrees Celsius three days before. Two days prior to admission, he developed a severe sore throat to the point where he could not eat much, so he sought medical attention. He is an MSM (man who has sex with man) who engages in both receptive and insertive sexual practices and had multiple partners and high-risk sexual intercourse without condoms including oral sex. The last sexual intercourse was 10 days before symptoms occurred.

On examination, body temperature was 36.9 degrees Celsius and other vital signs were within the normal limit. His throat was injected, tonsils were not swollen. There was no lymphadenopathy on his neck. There was an ulcer on his uvula (Fig. A). On laboratory tests, white blood cells were elevated to 10,300/μL, and renal function, liver function, and electrolytes were all unremarkable. A rapid test of group A streptococci was negative. He was started with acyclovir 5 mg/kg IV every 8 h for suspicion of HSV infection, ceftriaxone 2 g IV every 24 h for suspicion of Neisseria gonorrhoeae, minocycline 100 mg IV every 12 h for suspicion of Chlamydia trachomatis. Within two days of starting treatment, his sore throat improved, and he was able to eat, therefore, we switched to oral medicine with amoxicillin/clavulanate, minocycline, and valacyclovir. The swab culture of pharynx turned out to be negative, and PCR tests of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum, and Ureaplasma parvum were negative, the RPR (rapid plasma reagin) titer increased to 1:2 which had previously been negative. TPHA (treponema pallidum hemagglutination test) was also positive, and the titer was 1:1280. So, we added Benzylpenicillin 240 million units intramuscularly. His sore throat completely subsided (Fig. B) after Benzylpenicillin intramuscular shot without any recurrence.Fig. A Painful ulcer on the uvula with exudate.

Fig. A

Fig. B Completely cured uvula ulcer.

Fig. B

Discussion

The most common cause of pharyngitis is respiratory viruses and group A streptococci [5]. However, especially among those who are sexually active, we need to keep in mind sexually transmitted diseases such as Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum, and syphilis as well. There is an increased report of the prevalence and incidence of pharyngeal gonorrhea [6,7]. In this case, rapid antigen test for group A streptococci by rapid test was negative, so we broaden the differential to other sexually transmitted infections because he had been sexually active with multiple partners and had frequent oral sex without condoms. All tests for sexually transmitted infections except syphilis were negative. Routine blood draws in the outpatient including RPR titer had been negative until 3 months prior, but the RPR titer which was taken at the beginning of the symptom increased up to 1:2, so syphilis was the culprit at this time. Because syphilis is an uncommon cause of pharyngitis, it presents such a diverse clinical picture, the so-called “great masquerader”, so we must always consider it as a differential diagnosis.

From the prevention standpoint, this case has important implications. Patients who have high-risk behaviors have concurrent sexually transmitted diseases such as gonorrhea and chlamydia. Screening for all causes and treating appropriately, as in this case, is important in terms of minimizing transmission to others.

Conclusion

Sexually transmitted infections are uncommon causes of pharyngitis, but we should keep in mind that these may cause pharyngitis and uvula ulcers among patients who have high-risk behavior.

CRediT authorship contribution statement

Koko Shibutani: Writing – original draft. Nobuyoshi Mori: Writing – review & editing.

Source of financial support

This article did not receive any funding.

Author Agreement Statement

We the undersigned declare that this manuscript is original, has not been published before, and is not currently being considered for publication elsewhere.

We confirm that the manuscript and the revised manuscript have been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that all have approved the order of authors listed in the manuscript.

We understand that the Corresponding Author is the sole contact for the Editorial process. He/she is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs.

Ethical approval

As for this case report entitled “Syphilitic uvula ulcer”, written informed consent was obtained from the patient to publish this case report.

A copy of the written consent form is available.

Declaration of Competing Interest

The authors have no conflicts of interest directly relevant to the content of this article.

Acknowledgments

Not applicable.

Conflict of Interest statement

The authors have no financial conflicts of interest to disclose.

Consent

Written informed consent was obtained from the patient for the publication of this case report and accompanying images.
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