The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Stephanie V. Sherman, M.D., Editor

Gastric Syphilis
A B

C D

A
32-year-old man presented to the internal medicine clinic Yulian Wang, M.Med.
with a 2-week history of epigastric pain, nausea, anorexia, and weight loss. Jianhua Wu, M.D.
Physical examination was notable for epigastric tenderness. A computed Changhai Hospital
tomographic scan of the abdomen showed mural thickening of the gastric antrum. Shanghai, China
Endoscopy revealed an ulcer measuring 4.0 cm by 5.0 cm in the gastric antrum weilaiyisheng626@163.com
(Panel A) and an ulcer measuring 1.2 cm by 1.2 cm on the greater antral curvature This article was published on March 2,
(Panel B). Biopsy samples of the ulcers showed infiltration of lymphocytes, neutro- 2024, at NEJM.org.
phils, and plasma cells. There were no malignant features. Further history taking
revealed that the patient had had a genital ulcer 1 month before presentation. A
subsequent serum Treponema pallidum particle agglutination test was positive, and
the rapid plasma reagin (RPR) titer was 1:128. Immunohistochemical staining of
the ulcer-biopsy specimens for T. pallidum was positive (Panel C). Testing for the
human immunodeficiency virus was negative. A diagnosis of gastric syphilis was
made. Once-weekly injections of penicillin G benzathine were given for 3 weeks.
Two weeks after the patient began treatment, his symptoms had abated. Four
months after the completion of treatment, repeat testing showed that the RPR
titer had decreased to 1:4, and a repeat endoscopy showed that the ulcers had
resolved (Panel D, arrows).
DOI: 10.1056/NEJMicm2310836
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