CASE REPORT Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50

DOI: 10.1515/sjdv-2016-0005

Condyloma Latum on the Lower Lip as an Isolated Manifestation

of Secondary Syphilis – a Case Report
Milan BJEKIĆ1*, Kiro IVANOVSKI2
1
City Institute for Skin and Venereal Diseases, Belgrade, Republic of Serbia
2
Periodontology and Oral Pathology Department, Faculty of Dentistry, University St Cyril and Methodius, Skopje,
Republic of Macedonia

*Correspondence: Milan Bjekić, E-mail: [email protected]

UDK 616.59:616.317]:616.972

Abstract
Oral lesions are described in all stages of syphilis, except in the latent stage. During the secondary stage of infection,
oral lesions, saliva and blood of infected person are very contagious. The aim of this case report was to point to the
secondary syphilis in differential diagnosis of oral diseases.
A 30-year-old homosexual man presented with a three-week history of a painless verrucous lesion on his lower lip.
Physical examination revealed a hypertrophic painless papillomatous lesion on the lower lip. The lesion was partly split
with peripheral fissures. There were no generalized lymphadenopathies and no evidence of systemic disease. Further
examination showed no other mucous membrane or cutaneous lesions elsewhere on the body. The external genitalia
were normal. The patient was HIV-negative and otherwise healthy. A review of his medical history was significant for
previous well documented treatment of anal chancre, which was successfully commenced at our Institute in 2010. It
also revealed a history of a single unprotected receptive oral sex with an unknown partner 3 months before the onset
of lesion. The diagnosis of condyloma latum on the lower lip was considered on clinical grounds. Laboratory findings,
including complete blood count and blood chemistry were within normal limits. The VDRL (venereal disease research
laboratory) test was positive with a titre of 1 : 128. Treponema pallidum hemagglutination assay (TPHA) was positive.
HIV serology was non-reactive.
The final diagnosis of solitary condyloma latum on the lower lip, as the only sign of secondary syphilis, was confirmed
by positive results of routine serologic tests for syphilis. The patient was diagnosed with secondary syphilis and treated
with a single intramuscular injection of benzathine penicillin, 2.4 million units. The lesion regressed completely within 2
weeks. Three months later the VDRL titer had fallen to 1 : 8 and HIV serology remained negative.
Polymorphic oral manifestations in syphilis indicate that this disease should not be overlooked in the differential
diagnosis of not only benign, but even malignant oral lesions.
In conclusion, as far as the world literature available to us is concerned, this would be the first report of isolated solitary
condyloma latum on the oral lip that, in the absence of any other clinical signs or symptoms of the disease, led to the
diagnosis of secondary syphilis.

Key words
Syphilis, Cutaneous; Lip Diseases; Treponema pallidum; Diagnosis, Differential; Treatment Outcome; Signs and Symptoms;
Case Reports

S yphilis is a sexually transmitted infection caused

by Treponema pallidum. The disease is known
as a multi-stage disease and it is characterized by
and/or lymphadenopathy with or without organ
involvement), latent (asymptomatic) and late; in 25%
of those who are untreated, the disease takes a chronic
diverse and wide-range clinical manifestations. If course. Oral lesions are described in all stages, except
untreated, syphilis progresses through four stages: in the latent stage. Oral ulcers may be seen at any
primary (chancre), secondary (mucocutaneous lesions stage, but particularly in secondary syphilis, during

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 M. Bjekić and K. Ivanovski
Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50 Condyloma latum on the lower lip as an isolated manifestation of secondary syphilis

the secondary stage of infection; oral lesions, saliva and lymphadenopathies and no evidence of systemic
blood of infected person are very contagious (1, 2) disease. Further examination showed no other mucous
In this report, we present a rare case of a solitary membranes or cutaneous lesions elsewhere on the
oral lesion, as an isolated manifestation as well as a body. The external genitalia were normal. The patient
diagnostic clue of secondary stage syphilis. It also was HIV-negative and otherwise healthy. A review of
underlines the importance of taking into consideration his medical history was significant for previous well
this “great imitator” in the differential diagnosis of oral documented treatment of anal chancre, which was
diseases and reviews oral manifestations of infectious successfully commenced at our Institute in 2010. It
syphilis. also revealed a history of a single unprotected receptive
oral sex with an unknown partner 3 months before the
Case report onset of lesion. The diagnosis of condyloma latum (CL)
A 30-year-old homosexual man presented with a on the lower lip was considered on clinical grounds.
three-week history of a painless verrucous lesion on Laboratory findings, including complete blood
his lower lip. Physical examination revealed a well- count and blood chemistry were within normal limits.
defined, round flat-topped, white in colour, non- The VDRL (venereal disease research laboratory) test
ulcerated hypertrophic painless papillomatous lesion was positive with a titre of 1 : 128. Treponema pallidum
on the lower lip. The lesion was partly split with hemagglutination assay (TPHA) was positive. HIV
peripheral fissures (Figure 1). There were no generalized serology was non-reactive.

Figure 1. Hypertrophic, raised, papillomatous lesion on the lower lip partly split with peripheral fissures

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CASE REPORT Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50

The final diagnosis of solitary CL on the lower lip, An extremely broad spectrum of skin and
as the only sign of secondary syphilis, was confirmed mucosal lesions are seen in patients with secondary
by positive results of routine serologic tests for syphilis. syphilis (7). Mucous membrane lesions in secondary
The patient was diagnosed with secondary syphilis and stage are extremely infectious. These are highly
treated with a single injection of benzathine penicillin, infectious and usually fairly painless ulcers (mucous
2.4 million units intramuscularly. The lesion regressed patches and snail-track ulcers) (1). Nevertheless, the
completely within 2 weeks. Three months later, the three manifestations are well recognized: condylomata
VDRL titer had fallen to 1 : 8 and HIV serology lata (CL), mucous patches and macular lesions.
remained negative. The latter usually occur on the hard palate and are
manifested as red flat to slightly raised lesions in the
Discussion form of pharyngitis. Mucous patches are painless, oval
The syphilitic infection is usually transmitted through or circular lesions covered with thin mucosa on which
sexual contact. It occurs through oral sex in at least shalow, rounded erosions covered with macerated
13% of cases and in one fifth to one third in men who scaling and erythematous edge can be seen. Present in
have sex with men (2). Oral lesions are among clinical 7 - 12% of secondary syphilis cases, the lesions may
manifestations in infectious syphilis. In the primary appear anywhere in the mouth, commonly on the
stage of disease lesions are the result of unprotected tongue and lips. Confluence of several denuded lesions
oral intercourse. Oral sex is commonly practiced by may occur on the tongue. They may be seen also on
sexually active male-female and same-gender couples the glans of the uncircumcised penis, inner vulva and
of various ages, including adolescents. Oral sex anus. Split papules are elevated mucous patches with
involves both giving and receiving oral stimulation to central fissures in the oral commissures. Furthermore,
the penis, the vagina, and/or the anus. Although the sometimes these patches make serpentine like lesions,
risk of HIV transmission by oral sex is small, other so-called “snail track” ulcers (1, 2). Special papular
sexually transmitted diseases especially gonorrhea, lesions in secondary syphilis are very contagious
syphilis and herpes are more easily transmissible CL, which have been reported in 9 - 44% of cases.
through oro-genital contact (3). During an outbreak CL may appear in two different forms: the first
of early syphilis in Belgrade, about 60% of cases includes flat moist papules, and the second elevated
contracted the disease by oral sex (4). verrucous or cauliflower-like papules or plaques
The primary lesion develops at the site of usually located in the oral commissures. The later
inoculation about three weeks (range 10 - 90 days) type, found in our patient, was described on the lower
after infection with Treponema pallidum. About 5% of lip. CL consists of flesh-colored or hypopigmented
all primary chancres are found in extra genital locations macerated papules or plaques. Their surface may
and the majority of them occur in the mouth (40 - be smooth, papillated or covered with cauliflower-
75%) although they can be observed on any part of like vegetations. Lesions in intertriginous areas may
the body (5). The lip is the most common extragenital erode or proliferate, forming elevated, brown, velvety
site for primary syphilitic lesions. Most lip chancres in plaques or grouped hyperthrophic nodular lesions
males tend to occur on the upper lip, in females on the that resemble raspberries (frambesiform syphilis). CL
lower lip. Primary syphilis of the mouth manifests as a tend to develop at sites where two body surfaces are in
solitary ulcer with irregular raised border, and usually apposition such as anogenital areas, scrotum, medial
on the lips or the tongue, accompanied by a cervical thighs and behind the ears. Constant moisture, friction
lymphadenopathy. Rare appearances of a chancre on the and maceration at these sites facilitate coalescence and
tonsils and the pharynx have been described, as well (6). growth of syphilitic papules, resulting in development
Without treatment, chancre resolves within 2 - of plaque-like condylomas. The common sites are the
8 weeks. Lesions of secondary syphilis erupt 3 to 12 genital and anal, less frequently, the oral commissures,
weeks after the appearance of the chancre, but may face, nasolabial folds, axillae, inframammary folds,
develop months later or in up to 15% of cases, before toe webs and umbilicus (8, 9). In secondary syphilis,
chancre disappears (2). moist, flat, papulonodular lesions of oral CL often

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 M. Bjekić and K. Ivanovski
Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50 Condyloma latum on the lower lip as an isolated manifestation of secondary syphilis

appear at the mucocutaneous junctions and on examination is a diagnostic test of choice in chancre
mucosal surfaces especially at the commissures of the and most lesions of secondary syphilis, especially CL
lips (1). and mucous patches. Dark-field microscopy was not
The secondary stage of syphilis usually recedes performed in our patient due to technical limitations.
in 2 to 12 weeks. However, the classic, above given The test is invalid for oral lesions because saprophytic
description is present only in 60% of cases, and treponemas that can not be differentiated from T.
various deviations are common (2). An accurate and pallidum are common in the mouth (2). In such cases,
thorough patient history is important, since the a lymph node aspirate can be examined by dark-field
diagnosis of secondary syphilis requires a high index microscopy. If the diagnosis is otherwise unequivocal
of clinical suspicion, because the primary stage may as a result of these examinations, or clinical evaluation
go undiagnosed. Furthermore, the primary stage of of typical lesions coupled with reactive serologic results,
syphilis may not develop in certain circumstances, such skin biopsy is recommended. Oral syphilitic lesions are
as in HIV positive patients (10). Not all patients present frequently seen as a diagnostic challenge to dentists,
with classic symptoms and clinical findings. These may who are usually the first to examine oral lesions. Biopsies
be subtile, transient, and easily overlooked. However, are occasionally the first examination performed, but
the infection is systemic, even in the absence of histologic findings are considered nonspecific and
symptoms, despite the fact that the most common and the diagnosis is usually made through serologic tests
recognizable manifestations are mucocutaneous (2). In (10). However, recently it has been suggested that the
ou patient the characteristic morphology of the lesion presence of plasma cell arteritis and plasma cell neuritis
present on the lip, a well-defined, raised, round, flat- represent a combination that has not been reported in
topped, white in colour, non-ulcerated hypertrophic any other pathologic condition of the oral cavity and
painless papillomatous lesion on the lower lip suggested may be specific enough to direct the clinician toward
a clinical diagnosis of condyloma latum. Although the the diagnosis of syphilis prior to clinical confirmation
primary stage of infection has not been registered in (11). Polymorphism of oral clinical findings in syphilis
our case, medical history and data indicated that the indicates that this disease should not be overlooked in
primary lesion may have been present. The obvious the differential diagnosis of oral lesions such as oral
and largest distinction between chancre, and CL are hairy leukoplakia, lichen planus, oral condylomata
ulcerations and papillomatosis, respectively. Moreover, acuminata, candidiasis and oral squamous cell
it has been postulated that CL often develop within the carcinoma (1, 2, 11). Early detection of characteristic
vicinity of the primary chancre (10). oral lesions facilitates the diagnosis and enables prompt
CL may mimic condylomata acuminata or treatment of syphilis.
bowenoid papulosis, which are associated with CL in our patient was a solitary lesion and the
human papillomavirus infection. However, being not only sign of secondarism, since there were no other
contagious, oral lesions are also described in the tertiary mucous membrane or cutaneous lesions elsewhere on
stage of syphilis (6). Gummas, destructive granulomas, the body, as well as no generalized lymphadenopathies
usually occur on the hard palate and tongue. They can and no other evidence of systemic disease. There were
ulcerate and cause bone destruction or perforation of several reports on cases of secondary syphilis with no
the palate. In contrast to CL, syphilitic leukoplakia is other lesions but oral, and in each case oral lesions
a large whitish homogenous area on the dorsal side of led to the diagnosis of secondary syphilis, without
tongue and can show malignant alteration. evidence of systemic disease, even without generalized
The diagnosis of CL is based on typical skin lymphadenopathies (12). However, contrary to our
lesions and positive serologic tests for syphilis, as in our case, the lesions were more extensive, multiple or
case. Dark field microscopy detects Treponema pallidum rather erosive (12, 13). Solitary condyloma latum was
based on characteristic morphology and motility. It reported, but on the umbilicus (9). In 2010, Vera et al,
can be used both for primary and secondary lesions, reported four patients with interdigital CL and reviewed
and it is a very valuable tool: sensitive, inexpensive the world literature since 1940, where 18 previously
and may be performed at the point of care. Dark-fild reported patients were found. Thus, in the total number

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CASE REPORT Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50

of 22 patients, they detected the following: an isolated p. 69.1-69.129.

interdigital space was affected in 50% of patients; besides 2. Sanchez MR. Syphilis. In: Wolff K, Lowell A, Katz GS, Gilchrest
BA, Paller AS, Leffell DJ, editors. Fitzpatrick's dermatology in
the interdigital CL, 82% of patients presented with other general medicine. 7th ed. New York: McGraw-Hill; 2008. p.
secondary skin lesion; CL was the only manifestation 1955-77.
only in 4 patients (18%) (8). 3. Hawkins DA. Oral sex and HIV transmission. Sex Transm
Infect 2001;77(5):307-8.
Conclusion 4. Bjekić M, Šipetić S. An outbreak of early syphilis in patients
registred at City Institute for Skin and Venereal Diseases in
As far as the world literature available to us is Belgrade from 2010 to 2012: a case series of 86 patients. Serbian
concerned, this the first report of an isolated solitary Journal of Dermatology and Venereology 2013;5(2):65-71.
condyloma latum on the lip that, in the absence of 5. Ficarra G, Carlos R. Syphilis: the renaissance of an old disease
with oral implications. Head Neck Pathol 2009;3(3):195-206.
any other clinical signs or symptoms of the disease, led 6. Bruce AJ, Rogers RS 3rd. Oral manifestations of sexually
to the diagnosis of secondary syphilis. transmitted diseases. Clin Dermatol 2004;22(6):520-7.
7. Bjekić M. Secondary syphilis in patients treated at the City
Acknowledgement Institute for Skin and Venereal Diseases in Belgrade from 2010
to 2014. Serbian Journal of Dermatology and Venereology
This study was supported by the Ministry of Science
2015;7(2):53-60.
and Technology of Serbia, through Contract No. 8. Vera CI, Bermejo A, Leiro V, Parra V, Samper A. Interdigital
175042 (2011 - 2014). condylomata lata. Dermatol Argent 2010;16(3):199-203.
9. Pavithran K. Solitary condyloma latum on the umbilicus. Int J
Abbreviations Dermatol 1992;31(8):597-8.
10. Carbone PN, Capra GG, Nelson BL. Oral secondary syphilis.
HIV - human immunodeficiency virus Head Neck Pathol 2016; 10(2):206–8.
VDRL - venereal disease research laboratory 11. Czerninski R, Pikovski A, Meir K, Casap N, Moses AE, Maly
TPHA - Treponema pallidum hemagglutination A. Oral syphilis lesions--a diagnostic approach and histo-
assay logic characteristics of secondary stage. Quintessence Int
2011;42(10):883-9.
CL - condylomata lata 12. de Swaan B, Tjiam KH, Vuzevski VD, Van Joost T, Stolz E.
Solitary oral condylomata lata in a patient with secondary
References syphilis. Sex Transm Dis 1985;12(4):238-40.
1. Scully C, Hegarty A. The oral cavity and lips. In: Burns T, 13. Mani NJ. Secondary syphilis initially diagnosed from oral
Breathnach S, Cox N, Griffiths C, editors. Rook’s textbook of lesions. Report of three cases. Oral Surg Oral Med Oral Pathol
dermatology. 8th ed. Oxford: Blackwell Publishing Ltd; 2010. 1984;58(1):47-50.

Condyloma latum na donjoj usni kao jedina manifestacija

sekundarnog sifilisa – prikaz slučaja
Sažetak
Uvod. Usna duplja može biti zahvaćena lezijama u odsustvo regionalne i generalizovane limfadenopatije,
svim stadijumima stečenog sifilisa. bio jedina klinička manifestacija infekcije. Nakon
Cilj rada bio je da ukaže na značaj lezija sekundarnog sprovedene terapije benzatin penicilinom G, promena
sifilisa u diferancijalnoj dijagnozi oralnih oboljenja. se promptno u potpunosti povukla.
Prikaz slučaja. U radu je dat prikaz tridesetogodišnjeg Diskusija. Polimorfizam kliničke slike u usnoj duplji
muškarca homoseksualne orijentacije koji se javio kod obolelih od sifilisa upućuje na značaj ovog
dermatologu zbog bezbolne verukozne promene na oboljenja u diferencijalnoj dijagnozi bolesti usne
donjoj usni koja je trajala tri nedelje. Anamnestički duplje poput čupaste oralne leukoplakije, lihena
podaci, klinička slika i pozitivni serološki testovi na planus, kondiloma izazvanih humanim papiloma
sifilis ukazali su na sekundarni stadijum oboljenja u virusima, oralne kandidijaze i karcinoma skvamoznih
kojem je condyloma latum na donjoj usni u odsustvu ćelija usne duplje.
drugih promena na koži i sluznicama, uključujući i Zaključak. Prema nama dostupnoj literaturi, ovo bi bio

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Serbian Journal of Dermatology and Venereology 2016; 8 (1): 45-50 Condyloma latum on the lower lip as an isolated manifestation of secondary syphilis

prvi objavljeni slučaj izolovanog solitarnog condyloma kog drugog znaka ili simptoma, predstavljao jedini
latum na sluznici donje usne, koji je u odsustvu bilo klinički znak sekundarnog sifilisa.

Ključne reči
Kutani sifilis; Bolesti usana; Treponema pallidum; Diferencijalna dijagnoza; Ishod terapije; Simptomi i znaci;
Prikazi slučajeva

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