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Otolaryngology

A Man With Asymptomatic Ulcerated White Plaques on the Soft Palate

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: February 2, 2023

JAMA Clinical Challenge

Article Information and Disclosures

Shuni Ying, MD¹;

Sheng Li, MD¹;

Jianjun Qiao, MD, PhD¹

Author Affiliations

¹Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China

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A man in his 60s with no significant medical history presented to the dermatology clinic for evaluation of a gray-white plaque on his soft palate. These findings developed over the prior week and did not improve after treatment with 3 days of oral cefuroxime. The patient reported no sore throat, dysphagia, hoarse voice, cough, dyspnea, nausea, vomiting, headache, fever, night sweats, weight loss, rash, or genital, rectal, or oral ulcers over the past 6 months. He was taking no regular daily medications, did not smoke cigarettes, and had no history of oral trauma. Over the prior 6 months, he reported sexual contact with 1 male partner. Physical examination revealed irregular gray-white ulcers with a surrounding erythema on the soft palate, uvula, and tonsils (Figure 1) and nontender bilateral submandibular lymphadenopathy. His tongue was of normal appearance, and he had no skin lesions or mucosal erosions in the anal or genital areas.

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Secondary syphilis

A. Obtain serologic test results for Treponema pallidum

The key to the correct diagnosis is recognition that oral ulcers may be a manifestation of secondary syphilis. Oral biopsy (choice B) is an invasive procedure that should be considered if results of serologic tests for T pallidum are negative. Prescribing oral amoxicillin (choice C) is not recommended because the patient’s oral lesions did not improve with a recent course of cefuroxime. Topical nystatin (choice D) is incorrect because the patient did not have white patches on his tongue or inner cheek that are characteristic of oropharyngeal candidiasis.

Syphilis is an infection caused by T pallidum, a spirochete that is acquired predominantly through sex but that can be transmitted from mother to fetus during pregnancy and may rarely be acquired hematogenously or through an organ transplant.¹^- 3 Since 2000, syphilis has been increasing worldwide, and in 2019, approximately 39 000 patients in the US were diagnosed with primary or secondary syphilis.¹

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Article Information

Corresponding Author: Jianjun Qiao, MD, PhD, Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Rd, Hangzhou 310003, China (qiaojianjun@zju.edu.cn).

Published Online: February 2, 2023. doi:10.1001/jama.2023.0150

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References

Tuddenham S , Hamill MM , Ghanem KG . Diagnosis and treatment of sexually transmitted infections: a review. JAMA. 2022;327(2):161-172. doi:10.1001/jama.2021.23487 PubMed Google Scholar Crossref

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Schuch LF , da Silva KD , de Arruda JAA , et al. Forty cases of acquired oral syphilis and a review of the literature. Int J Oral Maxillofac Surg. 2019;48(5):635-643. doi:10.1016/j.ijom.2018.10.023 PubMed Google Scholar Crossref

Smith MH , Vargo RJ , Bilodeau EA , et al. Oral manifestations of syphilis. Head Neck Pathol. 2021;15(3):787-795. doi:10.1007/s12105-020-01283-4 PubMed Google Scholar Crossref

Lampros A , Seta V , Gerhardt P , Isnard C , Husson C , Dupin N . Oral forms of secondary syphilis: an illustration of the pitfalls set by the great imitator. J Am Acad Dermatol. 2021;84(2):348-353. doi:10.1016/j.jaad.2020.04.089 PubMed Google Scholar Crossref

Park IU , Fakile YF , Chow JM , et al. Performance of treponemal tests for the diagnosis of syphilis. Clin Infect Dis. 2019;68(6):913-918. doi:10.1093/cid/ciy558 PubMed Google Scholar Crossref

Luo Y , Xie Y , Xiao Y . Laboratory diagnostic tools for syphilis: current status and future prospects. Front Cell Infect Microbiol. 2021;10:574806. doi:10.3389/fcimb.2020.574806 PubMed Google Scholar Crossref

Forrestel AK , Kovarik CL , Katz KA . Sexually acquired syphilis: laboratory diagnosis, management, and prevention. J Am Acad Dermatol. 2020;82(1):17-28. doi:10.1016/j.jaad.2019.02.074 PubMed Google Scholar Crossref

US Preventive Services Task Force. Screening for syphilis infection in nonpregnant adolescents and adults: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2022;328(12):1243-1249. doi:10.1001/jama.2022.15322 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.