Endoscopic Aspects of Gastric Syphilis

Introduction. Considered as a rare event, gastric syphilis (GS) is reported as an organic form of involvement. Low incidence of GS emphasizes the importance of histopathological analysis. Objective. We aim to characterize GS endoscopic aspects in an immunocompetent patient. Case Report. A 23-year-old man presented with epigastric pain associated with nausea, anorexia, generalized malaise and 11 kg weight loss that started 1 month prior to his clinical consultation. Physical examination was normal except for mild abdominal tenderness in epigastrium. Endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions. Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes. Syphilis serologies were positive for VDRL and Treponema pallidum reagents. Immunohistochemical tests were positive for Treponema pallidum and CD138. The patient was treated with penicillin, leading to resolution of his clinical complaints and endoscopic findings. Conclusion. Diagnosis suspicion of GS is important in view of its nonspecific presentation. Patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.


Introduction
The first reports of syphilis occurred in the 15th century as a sexually transmitted disease. In the early 20th century, it was considered a relevant etiology in neurological and cardiovascular disorders with an increased incidence [1].
From the decade of 50, the advent of penicillin as well as public health measures provided a reduction in disease carriers. A new increase in reported cases was observed in the 80s, after the arise of acquired immunodeficiency syndrome [1].
Syphilis can be divided into three clinical stages that guide its treatment [1].
Although considered a rare event, gastric syphilis (GS) is reported as a form of organic involvement. Andral et al., in 1834, were pioneers by reporting two suspected cases of GS [2]. Other studies, in the next century, described a high incidence of GS diagnosis based on clinical, serological, and radiological evidences [3,4].
GS first case with histopathological confirmation in surgical specimen was reported by Graham [5]. Later, autopsy studies observed a lower incidence of GS, emphasizing the importance of histopathological analysis [6,7].

Objective
We aim to characterize GS endoscopic aspects in an immunocompetent patient.   anorexia, generalized malaise, and 11 kg weight loss that started 1 month prior to his clinical consultation at Internal Medicine Department of Clinics Hospital of Sao Paulo University. He had no other important symptoms, and his personal and family antecedents for gastrointestinal disorders, abdominal surgery, other diseases, or previous hospitalization were negative. Physical examination was normal except for mild abdominal tenderness in epigastrium.

Case Report
Upper endoscopy observed diminished gastric expandability and diffuse mucosal lesions, from cardia to pylorus. Gastric mucosa was thickened, friable, with nodular aspect, and associated with ulcers lesions (Figure 1). Gastric biopsies were performed, and histopathological analysis resulted in dense inflammatory infiltration rich in plasmocytes ( Figure 2).
Laboratory investigations revealed normal hemoglobin, hematocrit, white blood cell count, and liver and kidney function. Serology for HIV was negative. Syphilis serologies were positive for VDRL and Treponema pallidum reagents.
Based on laboratory and endoscopic findings, the possibility of GS was raised, and further investigation proceeded with immunohistochemical tests, which were positive for Treponema pallidum and CD138 (Figure 2).
The patient was treated with 2.400.000 UI dose of penicillin, leading to resolution of his clinical complaints and endoscopic findings (Figure 3).

Discussion
The most common symptoms of GS are epigastric pain, anorexia, early satiety, nausea, vomiting, and weight loss [8,9]. Physical examination frequently does not contribute to the diagnosis [10].
Upper gastrointestinal bleeding often occurs in early stage of disease since that later stage is characterized by being devoid of blood supply to mucosa due to an endarteritis obliterans process. Gastric perforation and obstruction are rare but of serious complications [11][12][13].
A systematic review published in 2010 showed that the majority of patients with GS had no clinical history (87%) or Case Reports in Medicine physical examination (56%) compatible with syphilis. Based on that, proper association between medical and sexual history, physical examination, and especially the high degree of suspicion is required for diagnosis, in view of its difficulty and imprecision [10].
Syphilis serologies are often positive and correlated with the stage of infection. Serological tests include nonspecific and specific [14]. Nonspecific tests are VDRL (venereal disease research laboratory) and RPR (rapid plasma reagin). Specifics tests are FTA-Abs (fluorescent treponemal antibody absorption), TPHA (treponema pallidum haemagglutination test), and ELISA (enzyme-linked immunosorbent assay), in which they use T. pallidum antigens [15].
Histopathological analysis are compatible with endovasculitis, which includes arterial wall and submucosal layer thickening, perivascular cell infiltrate, diffuse lymphocytic, and plasmocytes infiltrate [8]. Vasculitis, manifested by endarteritis or endophlebitis, is a typical finding in other sites but is rarely observed in gastric samples, probably because endoscopic biopsies do not reach submucosal layer [28].
A finding of chronic inflammatory process similar to what is described the described suggests that syphilis should be investigated as a potential cause [8]. Hematoxylin-eosin analysis may indicate, but does not confirm, diagnosis because Treponema pallidum is not identified in this method. In these cases, more specific tests such as immunofluorescence are needed [28].
In summary, diagnosis suspicion of GS is extremely important in view of its nonspecific presentation. Young patients with gastric symptoms that mimic neoplastic disease should be investigated thoroughly based on the fact that clinical, endoscopic, and histological findings can easily be mistaken for lymphoma or plastic linitis.