Destructive Osteomyelitis Associated with Early Secondary Syphilis in An HIV-Positive Patient Diagnosed by Treponema Pallidum DNA Polymerase Chain Reaction

A 20-year old man who had sex with men (MSM) presented with destructive osteomyelitis of the sternal bone and diffuse maculopapular rash. During laboratory evaluation he was found to have secondary syphilis and HIV with viral load of 28,000 copies per milliliter and CD4 count of 251 cells per microliter. Surgical debridement and biopsy of the sternal bone was performed. The biopsy examination demonstrated bone necrosis with perivascular infiltration of plasma cells and lymphocytes and rare hystiocytes. No granulomatous lesions were identified and acid-fast, fungal, silver, and Gram's stains did not show any organism. All cultures were negative. Real-time polymerase chain reaction (PCR) using probes targeting a pathogen-specific and highly conserved TpN47 gene of Treponema pallidum was performed on the DNA, extracted from the biopsy specimen and T. pallidum amplicons were detected. Patient was initially treated empirically with vancomycin, piperacillin/tazobactam and intravenous aqueous penicillin G. After confirming the diagnosis he completed 2 weeks of intravenous aqueous penicillin G treatment with resolution of osteomyelitis confirmed at follow-up visit after 6 weeks. Osteomyelitis is a rarely described manifestation of secondary syphilis. To the best of our knowledge, this is the first case of using T. pallidum DNA PCR to confirm the diagnosis of syphilitic osteitis. We suggest that osteomyelitis may be an underrecognized problem in patients with secondary syphilis, especially in HIV-coinfected individuals and PCR seems to be a valuable method in confirming the diagnosis.