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Source: Consultant, May 1997 v37 n5 p1243(2).

Title: Diagnosing oral manifestations of sexually transmitted diseases.
Author: M. Michelle Berrey and Lawrence Corey

Abstract: Many local and systemic infectious diseases have oral
manifestations. Sexually transmitted diseases (STDs) that manifest in the oral
mucosa include herpes simplex, secondary syphilis, gonococcal pharyngitis,
chlamydial infection, acute HIV seroconversion, erythematous candidiasis and
Kaposi's sarcoma. The diagnosis of oral manifestations of STDs should be
confirmed with cultures and serologic tests.

Subjects: Sexually transmitted diseases - Diagnosis
Oral manifestations of general diseases - Diagnosis

Business Collection: 103T4482
Electronic Collection: A19934579
RN: A19934579

Full Text COPYRIGHT 1997 Cliggott Publishing Co.

Your patient complains of a persistent sore throat and has hemorrhagic spots
of 3 to 4 mm in diameter on the oropharynx. Under what circumstances should
you include sexually transmitted disease (STD) in the differential diagnosis?

Diagnosis of oral lesions may require more than clinical acumen. Many
infectious agents manifest themselves in the oral mucosa [ILLUSTRATION
OMITTED] and require culture or serologic tests for definitive diagnosis. Both
local and systemic infections may present with painful oral hemorrhagic
lesions.

A detailed sexual history, which includes oral-genital contact, may expose
risk factors for sexually transmitted infections, such as herpes simplex.
However, the hemorrhagic lesions described above may just as easily represent
other infectious diseases. STDs with similar oral manifestations include
secondary syphilis; gonococcal pharyngitis; chlamydial infection; and acute
HIV seroconversion[1] or other oral infections seen in HIV-infected persons,
such as erythematous candidiasis[2] and Kaposi's sarcoma. Also, consider
infections that are not preferentially transmitted by sexual contact, such as
infectious mononucleosis and coxsackievirus infection (hand-foot-and-mouth
disease).

Syphilis. Primary oral syphilis is perhaps best known for creating a painless
change on the mouth, but many patients have petechial hemorrhage of the soft
palate or pharynx. In fact, the most common extragenital site of syphilis is
the mouth.[3] Non-tender cervical adenopathy should raise the suspicion of
primary oral syphilis; obtain the results of serologic tests (Venereal Disease
Research Laboratory [VDRL], rapid plasma reagin [RPR], fluorescent treponemal
antibody absorption [FTA-ABS], or microhemagglutination assay-Treponema
pallidum [MHA-TP]) to confirm the diagnosis.

A patient with very early primary syphilis (during the first 3 or 4 weeks of
infection) may have negative results of VDRL or RPR tests, but the treponemal
antigen test results should be positive. Darkfield microscopic examination of
lip lesions can also confirm the presence of the spirochete (treponemes other
than T pallidum are seen on darkfield examination of other oral lesions).

If left untreated, the disease will progress to the systemic phase of
infection: secondary syphilis. Oral lesions in the form of mucous patches may
accompany the papular cutaneous rash often seen on the trunk, palms, and
soles, or they may be the sole physical finding during this phase.[3]

Gonorrhea. This may present with oral manifestations in up to 20% of cases.
Diffuse erythema is more common than discrete lesions, but either may
predominate. Oral-genital contact with an infected person is the most common
route of infection. Secondary oral infections from lesions of the genital
mucosa may also occur.[3] Culture on Thayer-Martin medium is the most
cost-effective means of definitive diagnosis.

Chlamydial infection. Chlamydial pharyngitis may present as a painful or
painless mucositis with erythematous or pustular lesions on the oral mucosa.
Cervical lymphadenopathy is a common physical finding.[4]

Trichomonal infection. This may also cause oral symptoms, although diffuse
mucosal erythema is more common than discrete lesions.[4] Diagnosis is by wet
mount visual identification.

Herpes. Herpes simplex virus (HSV) may manifest itself as intraoral or
pharyngeal lesions in addition to the more common labial "cold sores." In
general, HSV pharyngitis is quite painful, and intraoral lesions may be
extensive. Acyclovir or one of the newer pro-drugs may decrease the duration
of symptoms and shedding of the virus.

HIV infection. Acute HIV seroconversion syndrome has been reported to include
oral lesions in up to 26% of symptomatic patients.[5] Fever is the most common
symptom, but pharyngitis and other symptoms related to the oral cavity are
common and may provide clues to the diagnosis. A detailed history to determine
recent exposure and serologic testing for antibody (which may be absent in the
acutely ill patient) or for viral RNA are required. Perhaps in 50% of
symptomatic seroconverters who present for treatment, the condition is
misdiagnosed, and what may be a crucial window for early therapy - and
certainly for early counseling - is missed?

Other diseases. Oral lesions that occur simultaneously with conjunctivitis,
nongonococcal urethritis, and arthritis are the hallmarks of Reiter's
syndrome. Other noninfectious but sexually related conditions include the
so-called fellatio syndrome of palatal petechiae, erythema, and ecchymoses
associated with repetitive negative pressure in the oral cavity.[4]

Several of the previously discussed STDs have serious sequelae if left
untreated. If you suspect an STD, obtain adequate cultures and serologic tests
to confirm the diagnosis; partners should be counseled and examined. In
addition, the health department must be notified of syphilis, gonorrhea, and
HIV infection cases.

REFERENCES:

1. McElrath MJ, Schacker T, Graham BS. Primary HIV-1 Infection. Principles and
Practices of Infectious Diseases. Update. 1997:1-19

2. Laskaris G. Oral manifestations of infectious diseases. Dent Clin North Am.
1996;40:395-423.

3. Siegel MA. Syphilis and gonorrhea. Dent Clin North Am. 1996;40:369-383.

4. Terezhalmy GT, Naylor GD. Oral manifestations of selected sexually related
conditions. Dermatol Clin. 1996;14:303-317.

5. Kinlock-de Loes S, de Saussure P, Saurat JH, et al. Symptomatic primary
infection due to human immunodeficiency virus type 1: review of 31 cases. Clin
Infect Dis. 1993;17:59-65.

6. Schacker T, Colier AC, Hughes J, et al. Clinical and epidemiologic features
of primary HIV infection. Ann Intern Med. 1996;125:257-264.

Dr M Michelle Berrey, MD, MPH is a fellow in the infectious diseases section
at the University of Washington School of Medicine in Seattle; Dr Lawrence
Corey, MD is professor of medicine in the virology division at the same
institution.

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