case report anurag

8/7/2019 Case Report anurag

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Dr. Anurag JainP.G. Surgery


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Introductiony Case records of Massachusetts General Hospital.

y Published in New England journal of Medicine onFebruary 25, 2010.


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Complaintsy 37 year old homosexual man presented at oral and

maxill0facial surgery clinic at Massachusetts General

Hospital with complaints of :-1. Painful lesion on the tongue 3 weeks.

2. Painful nodule on the left side of the neck 3 weeks.

3. Itchy lesions on both legs 3 weeks.


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History of Presenting Illnessy Patient first noticed a small lesion on the left side of

the tongue 3weeks back. Lesion was painful.

y At the same time he noticed a painful nodule on theleft side of the neck which appeared spontaneously.

y Few days later patient noticed itchy lesions on bothlegs which he thought to be an allergic reaction topoison ivy, for which he was exposed several weeks

earlier. Some of the lesions have developed intoblisters which were open & draining.

y No history of fever, chills, nausea, vomiting, fatigue &recent weight loss.


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Treatment historyy For the same patient received empirically 5 days

course of acyclovir and 10 days course of

sulfamethoxazole trimethoprim with no relief.


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Past historyy Patient was operated for tonsillectomy and

adenoidectomy in past.

y Patient also have history of border line hypertensionand asthma.

y Patient was allergic to penicillin and cephalexin.


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y Family history -y His father has a history of myocardial infarction.

y Mother has thyroid disease.

y One near relative had melanoma.

y Personal history-

y Occasionally he used to take alcohol.

General and systemic examinations werewithinnormal limits.


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Examinationy A tender irregular shallow ulcerated lesion on left

ventral surface of tongue of 1.5 cm in diameter withsurrounding erythema. Surface was covered with whitefilmy layer which cannot be removed by gauze.

y Mobile smooth tender lymph nodes in the left anteriorcervical chain, size approx. 1-2 cm in diameter.

y Scattered areas of erythema and blisters were present

on the lower legs. Some blisters were open anddraining.

y one cloudy blister on right foot with 5 mm ofsurrounding erythema was present.


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Investigationy HIV Non Reactive

y Culture of tongue lesion was negative for herpes simplexvirus.

y Culture of the cloudy blister on the foot grew methicillinsensitive staphylococcus aureus.

y CT scan of head & neck showed a well defined low densitylesion on the ventral surface of tongue with littlesurrounding enhancement with no evidence of appreciablesub mucosal infiltration. Bilateral enlarged lymph node,

with smoothly marginated capsule and no evidence ofnecrosis.

y Punch biopsy was taken from the tongue lesion.


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Focused differential diagnosisy Secondary syphilis

y Erythema multiforme

y Major apthous ulcery Squamous cell carcinoma


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Final diagnosisy Oral syphilis as per biopsy report which was

confirmed by rapid plasma reagent test.


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Discussiony Features of syphilis of oral cavity

y Shallow tongue ulcer.

y

Chancre of syphilis when located on penis or vulva aretypically painless, but they can be painful when located onthe tongue, fingers and anus.

y The oral ulcer of secondary syphilis are often associated withmaculopapular skin lesion on the extremities and this patient

had skin lesions which have become superinfected withstaphylococcus aureus.

y Inflammatory tender lymphadenopathy.

y Usually seen in male homosexuals and associated with HIV.


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THANK YOU

case report anurag

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