Gastric syphilis: The great imitator in the stomach
Syphilis is resurging worldwide. This is the case of a 33-year-old heterosexual man who presented with a 3-week history of epigastric pain, nausea, emesis, and 8 kg weight loss. He was subsequently diagnosed with gastric syphilis, based on reactive syphilis serological testing and Treponema pallidum found in gastric biopsy specimens. Gastric syphilis is a rare presentation observed in 1% of cases and usually develops in secondary syphilis. Given the nonspecific manifestation and findings, a high index of suspicion is required for diagnosis of gastric syphilis.

A 33-year-old heterosexual man without past medical history presented with a 3 week history of epigastric pain, nausea, emesis, and 8 kg weight loss. He also noted generalized rashes around the same time. Three months prior, he developed a lesion near the urethral meatus, which subsided spontaneously.

Physical examination revealed faint macular rashes over the abdomen and back. Enlarged, elastic soft, non-tender lymph nodes were present in the posterior cervical and inguinal areas bilaterally. The abdomen was soft and with normal bowel sounds. There was mild tenderness in the epigastric area without guarding. There were no genital lesions. The rapid plasma reagin test (RPR) and the Treponema pallidum latex agglutination test were both highly reactive at 99.2 RPR units (roughly equivalent of 1:64–128) and 2723 titer units (normal range: <10 titer units), respectively.

Upper gastrointestinal endoscopy revealed diffuse erythema, edematous and friable changes, and irregular erosions involving the entire stomach, except for the greater curvature of the corpus. The gastric biopsy specimens exhibited diffuse infiltrations of inflammatory cells (predominantly plasma cells) in the lamina propria and a loss of ductal structures. Numerous spirochetes were observed by immunohistochemical staining using a monoclonal antibody against T. pallidum. He received a 14-day course of high dose amoxicillin and probenecid, which gradually resolved all symptoms.

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