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[위매독. Gastric syphilis]
최근 위매독(gastric syphilis)가 조금씩 증가하고 있는 듯 합니다. 전체적으로 매독이 증가하고 있으므로 위매독도 따라서 증가하는 모양입니다. 우리나라에서 매독 환자는 생각보다 많습니다. 2008년의 경우 1,548명이었다고 합니다 (Clin Endosc 2015;48:256). AIDS 때문에 다른 성병이 무시되고 있기 때문인 것으로 추정하고 있습니다.
Gastric syphilis의 특징을 정리하면 아래와 같습니다.
1. Secondary and tertiary stage
2. Incidence in syphilis; <1%
3. Endoscopy; erosive gastritis or gastric ulcer with heaped, nodular edges or thickened, edematous rugal folds.
4. Histopathologic findings; suggestive, but not diagnostic
제가 지금까지 알고 있는 gastric syphilis 6예의 사진입니다. 특히 첫번째 증례가 보만 4형 진행성 위암과 비슷했습니다.
Clinal Endoscopy 2015년 5월호에 신증후군을 동반한 위매독 증례가 소개되었습니다.
Gastroscopic findings. Multiple irregular, shallow ulcers covered with whitish exudates and central depression in the (A) antrum, (B) body, and (C) cardia.
Histologic findings of gastric biopsy. (A) Marked severe inflammation with lymphoplasmacytic infiltrates (H&E stain, ×400). (B) Numerous spirochetes are present between foveolar epithelial cells (Warthin-Starry stain, ×1,000).
CPC case: gastric syphilis
History: A 25-year-old, apparently healthy man presented with one month history of epigastric tenderness and vomiting. The patient visited a local clinic where he underwent an endoscopic examination and the endoscopic diagnosis was benign gastric ulcer. But gastric ulcer symptom was not improved on ulcer medication. He was transferred to our hospital for further evaluation. His family history and past medical history were negative for any gastrointestinal disease, abdominal surgery or significant medical illness. Physical examinations were normal except minimal epigastric tenderness only. A laboratory evaluation revealed hemoglobin of 16.4 g/dL and hematocrit 47.9%. White blood cell count and differential count were within normal ranges. Total serum protein level was 7.3 g/dL and albumin level 4.3 g/dL.? Serum bilirubin and liver enzymes were within normal ranges. A computed tomographic scan of the abdomen with contrast revealed diffuse layered thickening of the wall of the gastric antrum, pylorus, duodenal bulb, and second portion of duodenal loop without definite perigastric and periduodenal fatty infiltration (Fig. 1). Multiple small and enlarged lymph nodes were identified along both common femoral vessel and inguinal area. Gastric endoscopy showed geographic irregular ulcer and shallow depressed mucosal lesions in almost all aspect of antrum. The ulcer revealed an irregular edge and uneven nodular base (Fig. 2). Endoscope was failed to advance to duodenal bulb due to luminal obstruction. A diagnostic procedure was done.
Biopsy: Chronic gastritis, active, with intestinal metaplasia (incomplete type), large lymphoid follicle and dense lymphoplasma cell infiltration ( Note: Based on histology, syphilitic gastritis could be considered)
Layered wall thickening involving gastric antrum, pylorus, duodenal bulb,and 2nd duodenal loop
Automated Quantitative RPR Test: Reactive(5.00)
Automated Quantitative TPLA Test: Reactive(282.9)
A: foveolar pit 에서 H.pylori 가 관찰되지 않는다. B: 심한 위염소견으로 neutrophilic infiltration 이 관찰된다. C: lamina propria 에 심한 lymphoplasma cell infiltration 이 관찰된다. D: lagre irregular lymphoid follicular hyperplasia with geographic feature
Large irregular lymphoid follicle : H.pylori 감염과는 달리 marginal zone 은 상대적으로 위축되어 있으나 follicular center 가 심하게 늘어나면서 지도모양(geographic feature) 으로 커져있다.
1. Mylona. Gastric syphilis: a systematic review of published cases of the last 50 years. Sex Transm Dis. 2010 Mar;37(3):177-83.
The authors conducted a systematic review of the English literature for cases of Gastric Syphilis (GS) in the last 50 years. The 34 studies which met selection criteria included 52 patients with GS. Of the reviewed patients, only 13% had a history of syphilis diagnosis and 46% had prior or concurrent clinical manifestations of the disease. Epigastric pain/fullness was the most common presenting symptom (92%) and epigastric tenderness being the most common sign. Gastric bleeding of variable intensity was documented in 35% of the cases. In the radiologic examinations, fibrotic narrowing and rigidity of the gastric wall was the most common finding (43%), followed by hypertrophic and irregular folds, while in endoscopy the most common lesion types were multiple ulcerations (48%), nodular mucosa, and erosions. The antrum was the most commonly affected area (56%). The majority of the patients received penicillin (83%) with a rapid resolution of their symptoms. Seventeen percent of the patients were treated surgically either due to a complication or due to strong suspicion of infiltrating tumor or lymphoma. The nonspecific clinical, radiologic, and pathologic characteristics of GS can establish it as a great imitator of other gastric diseases. GS should be considered in the differential diagnosis in patients at risk for sexually transmitted diseases who present with abdominal complaints and unusual endoscopic lesions and no other diagnosis is made, irrespective of the presence of H. pylori. The absence of primary or secondary luetic lesions should not deter one from considering GS.
© 일원내시경교실 바른내시경연구소 이준행. EndoTODAY Endoscopy Learning Center. Lee Jun Haeng.