A 19-year-old woman with a history of congenital angioma in a thigh and febrile seizures during childhood.
She presented with an oppressive left frontal headache accompanied by a centellant scotoma of the left eye, with one and a half month of evolution.
Two days prior to consultation, an increase in left frontal volume was added.
On physical examination, an axillary temperature of 37.5 °C, swelling in the left frontal region, painful upon admission to the emergency room, malaise and skin with mild erythema of the supradyac were found.
In the mouth he had an aphtha-like lesion on the lateral border of the tongue and a soft palate ulcer, with irregular edges, pale-rose, painless, ophagia.
The rest of the physical examination, including the articular and neurological ones, was normal.
In the laboratory, as relevant findings, erythrocyte sedimentation rate was 20 mm/h (normal value: 0-20 mm/h) and CRP was 8.86 mg/L (normal value: 0-5 mg/L).
HIV serology was negative.
The chest X-ray was normal and the tuberculin skin test (PPD) was negative.
A non-contrast computerized axial tomography (CAT) of the brain showed an osteolytic lesion of polished aspect that compromised the internal table, diploe and external table in the left frontal bone.
Magnetic resonance imaging (MRI) of the brain showed heterogeneous contrast uptake, associated with pachymeningeal reinforcement with thickening of soft tissues, with subgaleal location adjacent to the lesion.
A lumbar puncture was performed, obtaining a clear CSF without cells, normal glycorrhachia and proteinorrhachia; direct staining and cultures for bacteria, mycobacteria and bacteria were negative.
Cultures were taken from the edge and center of the oral ulcer for common bacteria, mycobacteria, Actinomyces, Non isolation and search for herpes simplex 1 and 2 antigens; all were negative.
Biopsy of the oral lesion was not performed.
Due to the preliminary negative microbiological results, and to the fact that the patient presented more headache, a bone biopsy and a biopsy of the affected meninge were performed.
Histopathological analysis showed lymphoplasmacytic infiltrate, with no evidence of multinucleated cells, granulomas or atypia, presence of fibrous tracts and absence of microorganisms in Ziehl-hartinS staining.
Immunostaining for ALK and desmin were performed with negative results, ruling out an inflammatory pseudotumor.
Reinterrupting the patient, she recalled a picture of a papular rash on elbows and knees, associated with joint inflammation with pharyngitis three months prior to the consultation, which had received benzathine penicillin.
For this reason, VDRL and FTA were performed in serum and CSF, both tests being positive in serum (VDRL 1:64) and negative in CSF.
The histopathological study was completed with a polymerase chain reaction (PCR) for T. gondii from bone biopsy material, which was positive.
1.
Due to the time elapsed between the first clinical manifestations and bone involvement, the concomitant mucosal lesion characteristic of syphilitic secondaryism and histopathological findings (absence of gomas), a secondary syphilis was interpreted as bone involvement.
Because the patient had a meningeal enhancement adjacent to the bone lesion, although the CSF was not inflammatory with negative VDRL, and because it was impossible to rule out a CNS involvement with crystalline penicillin weekly combined with intravenous penicillin G.
The patient had a good clinical response (immediate improvement after completion of treatment), resolution of imaging-nological findings and decreased plasma VDRL levels at six months (1:4).
Given the favorable response after antimicrobial treatment, it was decided not to advance with other therapeutic measures.
