Abstract

Syphilis is a chronic systemic infection with diverse oral manifestations that can mimic inflammatory, potentially malignant, and malignant disease. We present a case of an 80-year-old woman with recently diagnosed late latent syphilis referred for a painful,
friable white verrucous lesion of the anterior maxillary gingiva, associated with dental mobility and feeding difficulty. Initial incisional biopsy showed verrucous epithelial hyperplasia with parakeratosis, acanthosis, chronic inflammation, and spirochetes demonstrated by immunohistochemistry for Treponema pallidum. Despite intramuscular benzathine penicillin G and an appropriate serological response, the lesion persisted. A repeat biopsy showed atypical keratinizing squamous epithelial proliferation with lichenoid inflammation, raising concern for malignancy. Staging imaging showed localized maxillary gingival disease without suspicious cervical lymphadenopathy or thoracic metastases. Surgical excision with multiple dental extractions and reconstruction was performed. The resection specimen confirmed a 30 mm, well-differentiated verrucous carcinoma with 1 mm depth of invasion, expansile growth, no lymphovascular or perineural invasion, and pathological stage pT2. The sequential findings do not establish syphilis-related malignant transformation; lesion heterogeneity and sampling variability remain plausible. Persistent verrucous oral lesions require deep, representative biopsy, close clinicopathological correlation, and continued surveillance.

Keywords

• Syphilis, Latent
• Mouth Diseases
• Epithelial Cells
• Leukoplakia, Oral
• Inflammation, Chronic

References

• Ficarra, G.; Carlos, R. Syphilis: the renaissance of an old disease with oral implications. Head and Neck Pathol 2009, 3, 195–206. https://doi.org/10.1007/s12105-009-0127-0.
• Hicks, C.B.; Clement, M. Syphilis. In Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 9 ed.; Bennett, J.E.; Dolin, R.; Blaser, M.J., Eds.; Elsevier: Philadelphia, 2020.
• Janier, M.; Unemo, M.; Dupin, N.; Tiplica, G.S.; Potoˇcnik, M.; Patel, R. 2020 European guideline on the management of syphilis. J Eur Acad Dermatol Venereol 2021, 35, 574–588. https://doi.org/10.1111/jdv.16946.
• Gokavarapu, S.; Chandrasekhara Rao, L.M.; Patnaik, S.C.; Parvataneni, N.; Raju, K.V.V.N.; Chander, R.; Jeevan Kumar, K.A. Reliability of incision biopsy for diagnosis of oral verrucous carcinoma: a multivariate clinicopathological study. JJ Maxillofac Oral Surg 2015, 14, 599–604. https://doi.org/10.1007/s12663-014-0715-8.
• Richards, R.; Agarwal, S. Atypical squamous verrucous lesions of the oral cavity: challenges in interpretation of small incisional biopsies. Head Neck Pathol 2023, 17, 607–617. https://doi.org/10.1007/s12105-023-01558-6.
• Krištofelc, N.; Zidar, N.; Strojan, P. Oral verrucous carcinoma: a diagnostic and therapeutic challenge. Radiol Oncol 2023, 57, 1–11. https://doi.org/10.2478/raon-2023-0015.
• Coussens, L.M.; Werb, Z. Inflammation and cancer. Nature 2002, 420, 860–867. https://doi.org/10.1038/nature01322.
• Syrjänen, S. HPV infections and tonsillar carcinoma. J Clin Pathol 2004, 57, 449–455. https://doi.org/10.1136/jcp.2003.008656.
• Arduino, P.G.; Bagan, J.; El-Naggar, A.K.; Carrozzo, M. Urban legends series: lichen planus. Oral Dis 2013, 19, 128–143. https://doi.org/10.1111/j.1601-0825.2012.01953.x.

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Categories

• Oral Medicine

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