Previous Diagnosis

Late benign syphilis(gumma). See a little discussion

	This is a photo(sternal region) of a 33 yo male patient. He denies any kind of pain and reports that this lesion appeared three months ago smaller than now and grew up. Torax X-ray Try to make the diagnosis Having problems to partipate?
	We would like to thanks Eduardo Bruno Martins, M.D. D.Phil. for his great contribution.

Congratulations to:

Rodrigo Portugal - Rio de Janeiro - Brazil
Nilson Araujo-Brasil-Rio de Janeiro
Luiz Alexandre Cabral Pinto - Brasil - Rio de Janeiro
Raj Satyanarayana

Discussion

Although they may be very destructive, they respond rapidly to treatment and therefore are relatively benign. Histologically the gumma is a granuloma. The histologic findings are nonspecific and may be associated with central necrosis surrounded by epithelioid and fibroblastic cells and occasionally giant cells. There is sometimes vasculitis. T. pallidum is ordinarily not demonstrable by silver stains but can sometimes be recovered by inoculation of rabbits.

Gummas may be solitary or multiple. They are usually asymmetric and are often grouped. They may start as a superficial nodule or as a deeper lesion that breaks down to form punchedout ulcers. They are ordinarily indolent and slowly progressive with curving or polycyclic borders. They are indurated on palpation. There often is central healing with an atrophic scar surrounded by hyperpigrnented borders, cutaneous gummas may resemble other chronic granulomatous ulcerative lesions caused by tuberculosis, sarcoidosis, leprosy, and other deep fungal infections.

Precise histologic diagnosis may not be possible. However, the syphilitic gumma is the only such lesion to heal dramatically with penicillin therapy which was the case of this patient.

Another form of gumma is papulosquamous and may mimic psoriasis. Gummas may also involve deep visceral organs, of which the most common are the respiratory tract, the gastrointestinal tract and bones. In earlier centuries gummas of the nose and palate commonly resulted in septal perforations and disfiguring lacra lesions. Gummas may also involve the larynx or the pulmonary parenchyma. Gumma of the stomach may masquerade as carcinoma of the stomach or lymphoma.

Gummas of the liver were once the most common form of visceral syphilis, presenting often vith hepatosplenomegaly and anemia, occasionally with fever and jaundice, skeletal gummas typically produce lesions in the long bones, skull, and clavicle. A characteristic symptom is noctumal pain. Radiologic abnormalities, when present, include periostitis and either lytic or sclerotic destructive osteitis.

Reference