Primary seropositive syphilis with acute condylomas of the facial skin and perianal candidiasis

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BACKGROUND

Syphilis is an infectious human disease caused by Treponema pallidum, transmitted primarily by sexual intercourse and characterized by a progressive course with periodicity of clinical symptoms and lesions of the skin, mucous membranes, nervous system, internal organs, and musculoskeletal system [1–3].

Syphilis represents a significant contemporary challenge in dermatovenereology. In the countries of Eastern Europe, and notably the Russian Federation, the late 20th century was marked by a remarkably high prevalence of this infection. In the Russian Federation, a continuous increase in the incidence of syphilis was observed between 1990 and 1997. The highest number of cases was recorded in 1997, with an incidence of 277 per 100,000 population, which exceeded the 1989 rate by more than 60-fold. Presently, the syphilis morbidity rate remains high and is epidemiologically unfavorable [4].

From 2015 to 2019, a substantial decline in reported syphilis cases was observed, amounting to 12,394 fewer cases (representing a 36% decrease). The number of cases decreased from 34,426 in 2015 to 22,032 in 2019 [5].

In the Russian Federation, the incidence of nearly all infectious diseases exhibited a significant decline in 2020. For example, the incidence of acute enteritis, hepatitis, and tuberculosis decreased by 46%, 36%, and 23%, respectively, in comparison to 2019. This decline can be attributed to the implementation of several measures aimed at preventing the spread of the new coronavirus infection and organizing the provision of medical care to patients with COVID-19. These measures included the suspension of routine medical care in the dermatovenereology profile in 24-hour and day hospitals, as well as in outpatient settings, the re-profiling of 24-hour dermatovenereology beds, the suspension of preventive medical examinations and medical check-ups, the involvement of medical staff from specialized organizations in providing medical care to patients with COVID-19, quarantine measures, and the self-isolation of citizens [5].

In 2022, a marked increase in syphilis incidence was observed, with a 33% surge in registered cases compared with the previous year, resulting in a total of 25.7 thousand cases (Fig. 1). This surge was particularly pronounced in Moscow, where the number of syphilis cases detected in 2022 exceeded those of 2021 twice, accounting for nearly half of all new cases nationwide. Since 2019, the aggregate number of cases in Moscow has increased by nearly 4-fold, and the incidence rate among the population is five times higher than the average for the Russian Federation.^{1 2}

Fig. 1. Number of detected cases of syphilis in the Russian Federation according to Rospotrebnadzor data.

In addition, the Kostroma region (230% higher in 2022 than in 2019), Karelia (188% higher), and Tyva (154% higher) witnessed substantial increases in syphilis incidence. However, each region exhibited a lower population incidence rate compared with Moscow, that is 5.2, 3.8, and 63.3 per 100,000 in Kostroma region, Karelia, and Tyva, respectively, while the figure for Moscow was 80.6 per 100,000. A total of 33 regions documented an increase in syphilis incidence rates in 2022 compared with 2019 (Fig. 2). This substantial surge in incidence may be associated with the consequences of the COVID-19 pandemic. During the 2020 lockdown, the number of new syphilis cases decreased by 32% compared with the previous year (11% in 2019 and 15% in 2018). From May 2020 onward, a moderate decrease in the number of new cases was observed in comparison with the beginning of the year (see Table 1). However, in 2022, the incidence of the majority of infectious diseases remained below or close to the pre-pandemic level. Syphilis exhibited a notable exception, with a 23% increase in reported cases in 2022 compared to 2019 (except in Moscow, where the rate decreased by 18%).^{1 2}

Fig. 2. Number of detected cases of syphilis by region in the Russian Federation, according to Rospotrebnadzor data.

Table 1. Number of detected cases of syphilis in 2020 monthly according to Rospotrebnadzor data

According to Ogryzko et al. [6], the post-pandemic increase in syphilis morbidity in the Russian Federation is predominantly attributable to the migration factor. Although the number of foreign citizens who arrived in the Russian Federation in 2022 (16.9 million people) was 13% lower compared with 2019 (19.5 million people), the number of syphilis cases increased by 2.7-fold. Furthermore, the specific weight of syphilis detected in foreign citizens within the overall syphilis morbidity rate in the Russian Federation in 2022 increased by more than 2-fold compared with 2019. This phenomenon may be attributed to the implementation of mandatory screening for foreign citizens for high-risk infections, including syphilis, and the subsequent submission of the results to the Ministry of Internal Affairs of the Russian Federation.³ The results of the syphilis detection rate among foreign citizens and stateless persons in medical organizations of Moscow were obtained from 2013 to 2018. This study indicated the necessity of ongoing research to assess the frequency of detection of socially significant diseases among the aforementioned population in order to safeguard the social well-being of the Moscow population and facilitate the timely adoption of organizational decisions [7].

Concurrent Russian studies affirm that labor migration does not have a statistically significant impact on the spread of sexually transmitted infections, which is consistent with the conclusions of the European Regional Office of the World Health Organization [8]. However, Gluzmin et al. [9], based on a study conducted from 2001 to 2020, concluded that data on the incidence among migrants contribute significantly to the statistics of syphilis in the Kuban region. Accordingly, the incidence of syphilis among migrants was 210.7 per 100,000 tested in 2018 and 209.0 in 2019. In 2020, the rate exhibited a slight decrease to 196.8 per 100,000 people tested, with the average intensive rate for the region being 13.2 per 100,000. In 2021, however, the rate exhibited a substantial increase, reaching 238.6 (with the average intensive rate for the region standing at 15.0 per 100,000 inhabitants) [9].

Recent years have seen a notable increase in the incidence of syphilis among the population of the Republic of Tatarstan, with foreign citizens accounting for a considerable proportion of the registered cases. These data confirm their active involvement in the perpetuation of the epidemic as sources of infection. The annual identification of persons with socially significant infections is facilitated by the implementation of a wide range of clinical, laboratory, and instrumental methods of examination of foreign citizens. Foreign citizens within the republic constitute 25% of the syphilis cases registered among the population [10].

According to the statistics for 2014–2022, the trends in the spread of syphilitic infections in the Ural Federal District are characterized by an increased incidence rate among foreign citizens [11].

At the interregional scientific and practical conference “Dermatovenereology and Cosmetology: from Innovation to Practice,” the chief physician of the State Budgetary Healthcare Institution Samara Regional Dermatovenereological Dispensary, I.G. Shakurov, Dr. Sci. (Medicine), stated that competent examination of both local residents and migrants is necessary to reduce cases of syphilis [12].

The following is a case presented during a consultation at the Rakhmanov Clinic for Skin and Venereal Diseases.

CASE DESCRIPTION

Patient information

Patient D., a 34-year-old resident of Moscow, consulted a dermatologist, reporting cutaneous lesions in the lower third of the face and painful rashes in the perianal region.

Anamnesis morbi: According to the patient, the initial onset of cutaneous lesions on the lower jaw occurred at the end of August 2022. The aforementioned lesions were initially treated with electrocoagulation at a private clinic; however, the lesions recurred in early September 2022. Concurrently, the patient reported experiencing anal discomfort. Consequently, the patient consulted a local proctologist, where an anal fissure was diagnosed, and a treatment plan involving Relief Pro was prescribed. However, this treatment resulted in only modest improvements in the patient’s subjective sensations. On September 6, 2022, due to the torpidity of the skin condition, the patient sought further evaluation at the Rakhmanov Clinic for Skin and Venereal Diseases.

Anamnesis vitae. The patient’s marital status is recorded as “single.” The epidemiological history documented is that of a regular sexual partner, as stated by the patient. The most recent unprotected sexual intercourse occurred in early August 2022.

Status localis. The patient’s condition was satisfactory, and consciousness was clear. Nasal breathing was unobstructed, and vesicular breathing was present in the lungs, with no rales. The heart tones were clear and rhythmic, with a heart rate of 82 beats per min and a blood pressure of 125/80 mmHg. The abdomen was soft and painless. The lymph nodes in the left inguinal region were intact, while those in the right inguinal region were not palpated. The liver was located within the costal margin. Stool and diuresis were within normal range, and the body temperature was 36.9 °C.

Two ulcers, 2.0 cm and 1.0 cm in diameter, respectively, were identified on the skin of the gluteal region, set against an erythematous, macerated background. A lamellar infiltrate was palpated at the base of the ulcers. At the 11 o’clock position, closer to the anus, a scarring ulcer with a pink and saucer-shaped base was observed. A pear-shaped ulcerated defect with smooth edges was found above, apparently formed by the fusion of two ulcerated chancres. The ulcers were painless. The folds around the anus were swollen and covered with abundant white plaque (Fig. 3). Up to 25 small grouped papules of conical shape with clear borders, soft consistency, and a thin base in the form of a pedicle of normal skin color were visualized on the skin of the chin (Fig. 4).

Fig. 3. Ulcers on the skin of the gluteal region: close to the anus scarring ulcer with pink saucer-shaped bottom, above ― ulcerous defect of pear-shaped outlines with smooth edges.

Fig. 4. Small grouped cone-shaped papules on the skin of the chin.

Allergic history included a penicillin intolerance, manifesting as urticaria.

Results of physical, laboratory, and instrumental tests

The patient underwent laboratory and instrumental tests on September 7, 2022. Clinical blood count and biochemistry and urinalysis revealed no significant changes.

The nontreponemal test, known as the Rapid Plasma Reagin (RPR) test, yielded a result of 4+.

The results of the treponemal tests were as follows: enzyme immunoassay IgM 4+, IgG 4+, and passive hemagglutination assay 4+.

Dark-field microscopy revealed pale treponema (Treponema pallidum).

Antibodies to human immunodeficiency virus (HIV) types 1 and 2 (anti-HIV 1, 2 Ab) were not detected.

Furthermore, antibodies to the hepatitis B and C virus surface antigen (anti-HBs and anti-HCV IgG/IgM) in blood were not detected.

Candida albicans DNA was detected in a scraping from the anus folds by real-time polymerase chain reaction.

Diagnosis

Based on clinical data and laboratory tests, the diagnosis was primary seropositive syphilis (perianal chancres) with facial condyloma acuminata and anal candidiasis.

Treatment

Specific antisyphilitic treatment was prescribed, which included ceftriaxone 1.0 g intramuscularly, once daily for 14 days; fluconazole 150 mg, 1 capsule, once a week for 3 weeks; levocetirizine 5 mg, 1 tablet once daily, 1 h before injection, for 14 days.

Initially, the temperature reaction was 37.8 °C, indicative of a Jarisch-Herxheimer-Lukashevich reaction.

Following a comprehensive treatment targeting the underlying disease, condyloma acuminata on the facial skin were excised using the radio wave method on the Surgitron apparatus (Ellman, USA).

Outcome and follow-up

The patient received the full course of treatment: a total dose of 14.0 g of ceftriaxone administered intramuscularly, 450 mg of fluconazole, and 70 mg of levocetirizine. The treatment was well-tolerated by the patient.

The patient’s laboratory test results from October 3, 2022, included a negative RPR result, positive treponemal test results for IgM and IgG (4+), and a 4+ result for the passive hemagglutination test.

The patient is currently under the supervision of a dermatovenereologist at the place of residence, and the patient’s sexual partner is undergoing evaluation at a city dispensary.

It was recommended that clinical and serologic control be performed once every three months during the initial year of follow-up and subsequently once every six months in subsequent years, employing nontreponemal tests.

DISCUSSION

A clinical case of primary seropositive syphilis, characterized by perianal chancres, with facial condyloma acuminata and anal candidiasis is presented. This diagnosis of primary seropositive syphilis (perianal chancres) with facial condyloma acuminata and anal candidiasis was confirmed through a series of laboratory diagnostic tests, including RPR (4+), enzyme immunoassay IgM (4+), IgG (4+), and passive hemagglutination reaction (4+). Dark-field microscopy revealed pale treponema (T. pallidum).

Initially, a coloproctologist rendered an erroneous diagnosis, despite the patient’s history of unprotected sexual contact, the characteristic clinical pattern of the disease, and the localization of rashes, indicating the site of pathogen introduction.

A differential diagnosis is imperative for the accurate identification of condyloma acuminata, as it may be misinterpreted as other skin diseases, including condyloma lata, molluscum contagiosum, fibroepithelial papillomas, multiple sebaceous cysts, seborrheic keratosis, and soft fibromas. Furthermore, condyloma acuminata may serve as an indicator of immunodeficiency, necessitating laboratory diagnostic testing for HIV infection in each patient.

In response to the initiation of specific treatment, a reaction to the breakdown of pale treponemas (Jarisch-Herxheimer-Lukashevich reaction) manifested as chills and an increase in body temperature up to 37.8 °C. The control laboratory diagnostic tests indicated a return to normal values.

CONCLUSION

Syphilis remains a significant and pressing public health concern that demands the vigilance of healthcare professionals. Errors in syphilis diagnosis occur due to a lack of knowledge regarding the clinical manifestations and immunological aspects of this infection. Delayed diagnosis of syphilis prolongs the course of the disease and may result in late-stage infections.

Statistical data underscore the necessity of incorporating syphilis, a sexually transmitted infection, into the differential diagnoses of physicians of all specialties.

ADDITIONAL INFORMATION

Funding source. This study was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

Author's contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. N.S. Arsentev ― examination and treatment of the patient, development the concept of the article, editing and making the significant edits to the article in order to increase the scientific value of the clinical case; E.S. Sukhanova ― preparation and writing of the text of the article, literature review, collection and processing of clinical material to describe the clinical case.

Consent for publication. The patient voluntarily signed an informed consent for the publication of personal medical information in anonymised form in the Russian Journal of Skin and Venereal Diseases, as well as for the transfer of an electronic copy of the signed informed consent form to the journal’s editorial staff (date of signing 21.05.2024).

¹ rospn.gov.ru [Internet]. Russian Federal Service for Surveillance on Consumer Rights Protection and Human Wellbeing. Available at: https://www.rospotrebnadzor.ru

² rosstat.gov.ru [Internet]. Federal Service for State Statistics. Available at: https://rosstat.gov.ru

³ Federal Law No. 274-FZ of July 1, 2021, “On Amending the Federal Law ‘On the Legal Status of Foreign Citizens in the Russian Federation’ and the Federal Law ‘On State Dactyloscopic Registration in the Russian Federation.’” Available at: https://www.garant.ru/products/ipo/prime/doc/401315604/?ysclid=m3wmpubsld960673764

About the authors

Nikolai S. Arsentev

Email: kolendra@mail.ru
ORCID iD: 0000-0002-9866-7019

MD, Cand. Sci. (Medicine)

Elena S. Sukhanova

Author for correspondence.
Email: md.sukhanova.elena@gmail.com
ORCID iD: 0009-0003-4080-2921
Scopus Author ID: 58561406200
Russian Federation, Moscow

References

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2. Fig. 1. Number of detected cases of syphilis in the Russian Federation according to Rospotrebnadzor data.

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3. Fig. 2. Number of detected cases of syphilis by region in the Russian Federation, according to Rospotrebnadzor data.

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4. Fig. 3. Ulcers on the skin of the gluteal region: close to the anus scarring ulcer with pink saucer-shaped bottom, above ― ulcerous defect of pear-shaped outlines with smooth edges.

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5. Fig. 4. Small grouped cone-shaped papules on the skin of the chin.

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