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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 12 | 9 | 21 |
| 2024 Octubre | 93 | 69 | 162 |
| 2024 Septiembre | 93 | 43 | 136 |
| 2024 Agosto | 118 | 59 | 177 |
| 2024 Julio | 110 | 49 | 159 |
| 2024 Junio | 123 | 57 | 180 |
| 2024 Mayo | 108 | 50 | 158 |
| 2024 Abril | 87 | 20 | 107 |
| 2024 Marzo | 98 | 27 | 125 |
| 2024 Febrero | 110 | 34 | 144 |
| 2024 Enero | 114 | 36 | 150 |
| 2023 Diciembre | 120 | 20 | 140 |
| 2023 Noviembre | 101 | 54 | 155 |
| 2023 Octubre | 91 | 25 | 116 |
| 2023 Septiembre | 112 | 37 | 149 |
| 2023 Agosto | 101 | 39 | 140 |
| 2023 Julio | 132 | 32 | 164 |
| 2023 Junio | 93 | 22 | 115 |
| 2023 Mayo | 91 | 36 | 127 |
| 2023 Abril | 72 | 30 | 102 |
| 2023 Marzo | 86 | 31 | 117 |
| 2023 Febrero | 103 | 38 | 141 |
| 2023 Enero | 81 | 36 | 117 |
| 2022 Diciembre | 84 | 41 | 125 |
| 2022 Noviembre | 42 | 35 | 77 |
| 2022 Octubre | 79 | 20 | 99 |
| 2022 Septiembre | 77 | 45 | 122 |
| 2022 Agosto | 85 | 40 | 125 |
| 2022 Julio | 91 | 55 | 146 |
| 2022 Junio | 76 | 26 | 102 |
| 2022 Mayo | 111 | 51 | 162 |
| 2022 Abril | 75 | 46 | 121 |
| 2022 Marzo | 95 | 52 | 147 |
| 2022 Febrero | 79 | 33 | 112 |
| 2022 Enero | 127 | 37 | 164 |
| 2021 Diciembre | 107 | 32 | 139 |
| 2021 Noviembre | 105 | 62 | 167 |
| 2021 Octubre | 91 | 42 | 133 |
| 2021 Septiembre | 85 | 45 | 130 |
| 2021 Agosto | 81 | 34 | 115 |
| 2021 Julio | 82 | 32 | 114 |
| 2021 Junio | 57 | 39 | 96 |
| 2021 Mayo | 56 | 37 | 93 |
| 2021 Abril | 166 | 71 | 237 |
| 2021 Marzo | 62 | 32 | 94 |
| 2021 Febrero | 81 | 41 | 122 |
| 2021 Enero | 60 | 21 | 81 |
| 2020 Diciembre | 36 | 27 | 63 |
| 2020 Noviembre | 32 | 20 | 52 |
| 2020 Octubre | 49 | 10 | 59 |
| 2020 Septiembre | 45 | 13 | 58 |
| 2020 Agosto | 30 | 16 | 46 |
| 2020 Julio | 34 | 18 | 52 |
| 2020 Junio | 42 | 35 | 77 |
| 2020 Mayo | 30 | 35 | 65 |
| 2020 Abril | 36 | 29 | 65 |
| 2020 Marzo | 23 | 26 | 49 |
| 2020 Febrero | 7 | 14 | 21 |
| 2020 Enero | 0 | 13 | 13 |
| 2019 Diciembre | 5 | 13 | 18 |
| 2019 Noviembre | 0 | 15 | 15 |
| 2019 Octubre | 0 | 20 | 20 |
| 2019 Septiembre | 4 | 21 | 25 |
| 2019 Agosto | 0 | 19 | 19 |
| 2019 Julio | 1 | 20 | 21 |
| 2019 Junio | 11 | 30 | 41 |
| 2019 Mayo | 1 | 78 | 79 |
| 2019 Abril | 0 | 30 | 30 |
| 2019 Marzo | 3 | 15 | 18 |
| 2019 Febrero | 1 | 13 | 14 |
| 2019 Enero | 1 | 5 | 6 |
| 2018 Diciembre | 1 | 3 | 4 |
| 2018 Noviembre | 17 | 3 | 20 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Agosto | 0 | 18 | 18 |
| 2018 Julio | 0 | 7 | 7 |
| 2018 Junio | 0 | 6 | 6 |
| 2018 Mayo | 0 | 8 | 8 |
| 2018 Abril | 0 | 8 | 8 |
| 2018 Marzo | 10 | 8 | 18 |
| 2018 Febrero | 72 | 9 | 81 |
| 2018 Enero | 83 | 11 | 94 |
| 2017 Diciembre | 79 | 12 | 91 |
| 2017 Noviembre | 50 | 8 | 58 |
| 2017 Octubre | 67 | 9 | 76 |
| 2017 Septiembre | 49 | 16 | 65 |
| 2017 Agosto | 55 | 15 | 70 |
| 2017 Julio | 40 | 15 | 55 |
| 2017 Junio | 65 | 21 | 86 |
| 2017 Mayo | 82 | 11 | 93 |
| 2017 Abril | 46 | 16 | 62 |
| 2017 Marzo | 40 | 18 | 58 |
| 2017 Febrero | 77 | 11 | 88 |
| 2017 Enero | 60 | 16 | 76 |
| 2016 Diciembre | 72 | 14 | 86 |
| 2016 Noviembre | 82 | 33 | 115 |
| 2016 Octubre | 108 | 20 | 128 |
| 2016 Septiembre | 198 | 13 | 211 |
| 2016 Agosto | 178 | 9 | 187 |
| 2016 Julio | 76 | 9 | 85 |
| 2016 Junio | 6 | 10 | 16 |
| 2016 Mayo | 4 | 11 | 15 |
| 2016 Abril | 15 | 13 | 28 |
| 2016 Marzo | 12 | 12 | 24 |
| 2016 Febrero | 11 | 14 | 25 |
| 2016 Enero | 14 | 11 | 25 |
| 2015 Diciembre | 11 | 7 | 18 |
| 2015 Noviembre | 15 | 2 | 17 |
| 2015 Octubre | 7 | 7 | 14 |
| 2015 Septiembre | 10 | 1 | 11 |
| 2015 Agosto | 8 | 1 | 9 |
| 2015 Julio | 64 | 5 | 69 |
| 2015 Junio | 42 | 6 | 48 |
| 2015 Mayo | 48 | 8 | 56 |
| 2015 Abril | 39 | 6 | 45 |
| 2015 Marzo | 19 | 3 | 22 |
| 2015 Febrero | 43 | 2 | 45 |
| 2015 Enero | 31 | 2 | 33 |
| 2014 Diciembre | 32 | 2 | 34 |
| 2014 Noviembre | 37 | 1 | 38 |
| 2014 Octubre | 55 | 5 | 60 |
| 2014 Septiembre | 29 | 2 | 31 |
| 2014 Agosto | 26 | 1 | 27 |
| 2014 Julio | 23 | 3 | 26 |
| 2014 Junio | 44 | 1 | 45 |
| 2014 Mayo | 42 | 6 | 48 |
| 2014 Abril | 33 | 10 | 43 |
| 2014 Marzo | 37 | 2 | 39 |
| 2014 Febrero | 39 | 3 | 42 |
| 2014 Enero | 20 | 1 | 21 |
| 2013 Diciembre | 19 | 2 | 21 |
| 2013 Noviembre | 10 | 4 | 14 |
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