Case and Research Letters
Whitish Plaque on the Soft Palate
Placa blanquecina en el paladar blando
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Solano-López, D. de Argila, J. Fraga, A. García-Diez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Solano-López" "email" => array:1 [ 0 => "guitje1@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "de Argila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Fraga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "A." "apellidos" => "García-Diez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario de La Princesa, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Placa blanquecina en el paladar blando" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1001 "Ancho" => 1333 "Tamanyo" => 132461 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Irregular whitish plaque on the soft palate.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Secondary syphilis is known as the great imposter because of its many mucocutaneous presentations. While oral lesions occur in up to 30% of patients, mucosal involvement only is rare. Oral lesions include plaques, macules and papules, nodules, and ulcers.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of secondary syphilis with mucosal involvement only.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 34-year-old man with human immunodeficiency virus (HIV) infection under treatment with antiretrovirals who presented with asymptomatic whitish plaques on the fauces. The lesions had grown slowly in size over 8 months and there was no bleeding. Of note, 2 years earlier, coinciding with the diagnosis of HIV infection, the patient was also diagnosed with latent syphilis (VDRL titer of 1:16) by the infectious diseases department. He was prescribed doxycycline 100<span class="elsevierStyleHsp" style=""></span>mg for 14 days because of a possible allergy to penicillin. At the time, the physical examination revealed an irregular whitish plaque on the soft palate, the left tonsil, and the uvula that could not be removed by scraping (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no other lesions of interest. Considering the history of recurrent tonsillitis and the lack of response to antibiotics, a biopsy of the palatine tonsils was performed in the ear, nose, and throat department; the results suggested candidiasis and treatment was started with antifungals, but there was no improvement in the lesions. Two months later, a biopsy of the soft palate performed in the maxillofacial surgery department revealed a marked neutrophilic exudate with signs of epithelial regeneration and a slight inflammatory infiltrate (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Cultures of respiratory secretions were repeatedly negative for bacteria and fungi. Given the persistence of the lesions, the patient was referred to the dermatology department. Based on the patient's history and the clinical suspicion of secondary syphilis, the above biopsy samples were submitted for immunohistochemical analysis with polyclonal <span class="elsevierStyleItalic">Treponema pallidum</span> antibody (Biocare Medical). The results showed abundant spirochetes located predominantly in the epithelium and to a lesser extent in the underlying chorion (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) The treponemal tests were positive, with a VDRL titer of 1:4. The lesions resolved completely after a dose of 2.4 million units of penicillin benzathine. The patient received an additional 2 doses of intramuscular penicillin at weekly intervals, and 4 months later, was completely free of lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">HIV infection and immunodepression can alter the typical course of syphilis. Asymptomatic primary syphilis, for instance, is more common in patients with HIV infection, meaning that secondary manifestations are detected more frequently.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The differential diagnosis should include stomatitis, erythema multiforme, pemphigus, lichen, squamous cell carcinoma, candidiasis, oral gonococcal infection, and oral hairy leukoplakia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Oral secondary syphilis frequently presents a diagnostic challenge. The presence of oral saprophytic spirochetes limits the diagnostic utility of dark field microscopy. Histopathology frequently shows a nonspecific, predominantly plasmocytic infiltrate with epidermal hyperplasia. Warthin-Starry staining reveals spirochetes in up to a third of cases. Immunohistochemical staining of biopsy samples is currently considered to be a rather useful test for patients with false positive or negative serology results. The technique has a specificity of almost 100% and a sensitivity of 90%, rates that are higher even than those described for polymerase chain reaction analysis of tissue samples.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Apart from its high sensitivity and specificity, immunohistochemical staining can also be used to distinguish primary syphilis from secondary syphilis based on the location of the treponemes. While primary syphilis shows a mixed epitheliotropic and vasculotropic pattern, secondary syphilis shows an exclusively epitheliotropic pattern.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">We have presented the case of an immunodepressed patient who was referred to our department after several months of study with a whitish oral plaque that had been present for months. The plaque cleared within a week of administration of penicillin following confirmation of the suspected clinical diagnosis of secondary syphilis by immunohistochemistry. While syphilis reinfection cannot be ruled out, it is possible that doxycycline was ineffective because it is not a first-line drug or perhaps because the patient adhered poorly to the treatment. In patients allergic to penicillin, we recommend penicillin as the treatment of choice after prior desensitization. Dermatologists have an important role in the diagnosis of secondary syphilis, as many patients develop atypical lesions as an early manifestation.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">To conclude, diagnosis of secondary syphilis, the great imposter, continues to present challenges due to its multiple clinical manifestations. Immunohistochemical analysis of biopsy specimens may be a useful diagnostic tool in oral secondary syphilis with clinically and histologically atypical lesions and with negative serology for syphilis.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Solano-López G, de Argila D, Fraga J, García-Diez A. Placa blanquecina en el paladar blando. Actas Dermosifiliogr. 2013;104:834–835.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1001 "Ancho" => 1333 "Tamanyo" => 132461 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Irregular whitish plaque on the soft palate.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1332 "Ancho" => 1664 "Tamanyo" => 603497 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Biopsy of soft palate showing a marked neutrophilic exudate with signs of epithelial regeneration and a slight inflammatory infiltrate (hematoxylin-eosin, original magnification × 200).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1332 "Ancho" => 1664 "Tamanyo" => 624318 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Immunohistochemical staining of biopsy samples with polyclonal antibody against <span class="elsevierStyleItalic">Treponema pallidum</span> (Biocare Medical), showing abundant spirochetes in the epithelium and fewer spirochetes in the underlying chorion (original magnification × 100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Isolated oral erosions: an unusual manifestation of secondary syphilis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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Piérard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PAI.0b013e3181788186" "Revista" => array:6 [ "tituloSerie" => "Appl Immunohistochem Mol Morphol" "fecha" => "2009" "volumen" => "17" "paginaInicial" => "47" "paginaFinal" => "50" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18800002" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular syphilis: a rare presentation of secondary syphilis in an immunocompetent patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Hernández-Bel" 1 => "M.J. Gómez-Maestra" 2 => "A. Torrijos-Aguilar" 3 => "J. López" 4 => "J.J. Vilata" 5 => "V. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 9 | 21 |
| 2024 October | 93 | 69 | 162 |
| 2024 September | 93 | 43 | 136 |
| 2024 August | 118 | 59 | 177 |
| 2024 July | 110 | 49 | 159 |
| 2024 June | 123 | 57 | 180 |
| 2024 May | 108 | 50 | 158 |
| 2024 April | 87 | 20 | 107 |
| 2024 March | 98 | 27 | 125 |
| 2024 February | 110 | 34 | 144 |
| 2024 January | 114 | 36 | 150 |
| 2023 December | 120 | 20 | 140 |
| 2023 November | 101 | 54 | 155 |
| 2023 October | 91 | 25 | 116 |
| 2023 September | 112 | 37 | 149 |
| 2023 August | 101 | 39 | 140 |
| 2023 July | 132 | 32 | 164 |
| 2023 June | 93 | 22 | 115 |
| 2023 May | 91 | 36 | 127 |
| 2023 April | 72 | 30 | 102 |
| 2023 March | 86 | 31 | 117 |
| 2023 February | 103 | 38 | 141 |
| 2023 January | 81 | 36 | 117 |
| 2022 December | 84 | 41 | 125 |
| 2022 November | 42 | 35 | 77 |
| 2022 October | 79 | 20 | 99 |
| 2022 September | 77 | 45 | 122 |
| 2022 August | 85 | 40 | 125 |
| 2022 July | 91 | 55 | 146 |
| 2022 June | 76 | 26 | 102 |
| 2022 May | 111 | 51 | 162 |
| 2022 April | 75 | 46 | 121 |
| 2022 March | 95 | 52 | 147 |
| 2022 February | 79 | 33 | 112 |
| 2022 January | 127 | 37 | 164 |
| 2021 December | 107 | 32 | 139 |
| 2021 November | 105 | 62 | 167 |
| 2021 October | 91 | 42 | 133 |
| 2021 September | 85 | 45 | 130 |
| 2021 August | 81 | 34 | 115 |
| 2021 July | 82 | 32 | 114 |
| 2021 June | 57 | 39 | 96 |
| 2021 May | 56 | 37 | 93 |
| 2021 April | 166 | 71 | 237 |
| 2021 March | 62 | 32 | 94 |
| 2021 February | 81 | 41 | 122 |
| 2021 January | 60 | 21 | 81 |
| 2020 December | 36 | 27 | 63 |
| 2020 November | 32 | 20 | 52 |
| 2020 October | 49 | 10 | 59 |
| 2020 September | 45 | 13 | 58 |
| 2020 August | 30 | 16 | 46 |
| 2020 July | 34 | 18 | 52 |
| 2020 June | 42 | 35 | 77 |
| 2020 May | 30 | 35 | 65 |
| 2020 April | 36 | 29 | 65 |
| 2020 March | 23 | 26 | 49 |
| 2020 February | 7 | 14 | 21 |
| 2020 January | 0 | 13 | 13 |
| 2019 December | 5 | 13 | 18 |
| 2019 November | 0 | 15 | 15 |
| 2019 October | 0 | 20 | 20 |
| 2019 September | 4 | 21 | 25 |
| 2019 August | 0 | 19 | 19 |
| 2019 July | 1 | 20 | 21 |
| 2019 June | 11 | 30 | 41 |
| 2019 May | 1 | 78 | 79 |
| 2019 April | 0 | 30 | 30 |
| 2019 March | 3 | 15 | 18 |
| 2019 February | 1 | 13 | 14 |
| 2019 January | 1 | 5 | 6 |
| 2018 December | 1 | 3 | 4 |
| 2018 November | 17 | 3 | 20 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 0 | 3 |
| 2018 August | 0 | 18 | 18 |
| 2018 July | 0 | 7 | 7 |
| 2018 June | 0 | 6 | 6 |
| 2018 May | 0 | 8 | 8 |
| 2018 April | 0 | 8 | 8 |
| 2018 March | 10 | 8 | 18 |
| 2018 February | 72 | 9 | 81 |
| 2018 January | 83 | 11 | 94 |
| 2017 December | 79 | 12 | 91 |
| 2017 November | 50 | 8 | 58 |
| 2017 October | 67 | 9 | 76 |
| 2017 September | 49 | 16 | 65 |
| 2017 August | 55 | 15 | 70 |
| 2017 July | 40 | 15 | 55 |
| 2017 June | 65 | 21 | 86 |
| 2017 May | 82 | 11 | 93 |
| 2017 April | 46 | 16 | 62 |
| 2017 March | 40 | 18 | 58 |
| 2017 February | 77 | 11 | 88 |
| 2017 January | 60 | 16 | 76 |
| 2016 December | 72 | 14 | 86 |
| 2016 November | 82 | 33 | 115 |
| 2016 October | 108 | 20 | 128 |
| 2016 September | 198 | 13 | 211 |
| 2016 August | 178 | 9 | 187 |
| 2016 July | 76 | 9 | 85 |
| 2016 June | 6 | 10 | 16 |
| 2016 May | 4 | 11 | 15 |
| 2016 April | 15 | 13 | 28 |
| 2016 March | 12 | 12 | 24 |
| 2016 February | 11 | 14 | 25 |
| 2016 January | 14 | 11 | 25 |
| 2015 December | 11 | 7 | 18 |
| 2015 November | 15 | 2 | 17 |
| 2015 October | 7 | 7 | 14 |
| 2015 September | 10 | 1 | 11 |
| 2015 August | 8 | 1 | 9 |
| 2015 July | 64 | 5 | 69 |
| 2015 June | 42 | 6 | 48 |
| 2015 May | 48 | 8 | 56 |
| 2015 April | 39 | 6 | 45 |
| 2015 March | 19 | 3 | 22 |
| 2015 February | 43 | 2 | 45 |
| 2015 January | 31 | 2 | 33 |
| 2014 December | 32 | 2 | 34 |
| 2014 November | 37 | 1 | 38 |
| 2014 October | 55 | 5 | 60 |
| 2014 September | 29 | 2 | 31 |
| 2014 August | 26 | 1 | 27 |
| 2014 July | 23 | 3 | 26 |
| 2014 June | 44 | 1 | 45 |
| 2014 May | 42 | 6 | 48 |
| 2014 April | 33 | 10 | 43 |
| 2014 March | 37 | 2 | 39 |
| 2014 February | 39 | 3 | 42 |
| 2014 January | 20 | 1 | 21 |
| 2013 December | 19 | 2 | 21 |
| 2013 November | 10 | 4 | 14 |
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