Gumma, Causes, Diagnosis, Treatment

A gumma is caused by the bacteria that cause syphilis. It appears during late-stage tertiary syphilis. It most often contains a mass of dead and swollen fiber-like tissue. It is most often seen in the liver. It also can occur in the:

• Bone
• Brain
• Heart
• Skin
• Testis
• Eyes

Similar-looking sores sometimes occur with tuberculosis.

Diagnosis of Gumma

A series of comprehensive information are needed to be integrated before the diagnosis of neuro-syphilis, such as patient history, clinical manifestations, imaging, and serum and CSF tests.

Among laboratory tests, a positive CSF VDRL test has proven to be the most highly specific diagnostic criterion for syphilis, but with low sensitivity. Though the spinal syphilitic gumma in our case was not confirmed by operation pathology, the supportive laboratory tests and MRI findings in the patient could prompt diagnosis.

Treatment of Gumma

Penicillin G, administered parenterally, is the preferred drug for treating patients in all stages of syphilis. The preparation used (i.e., benzathine, aqueous procaine, or aqueous crystalline), dosage, and length of treatment depend on the stage and clinical manifestations of the disease.

Treatment for late latent syphilis (>1 years’ duration) and tertiary syphilis requires a longer duration of therapy because organisms theoretically might be dividing more slowly (the validity of this rationale has not been assessed).

Longer treatment duration is required for persons with latent syphilis of unknown duration to ensure that those who did not acquire syphilis within the preceding year are adequately treated.

Guidelines from the Centers for Disease Control and Prevention (CDC) recommend parenterally administered penicillin G for the treatment of all stages of syphilis.

The recommended treatment for patients with syphilis is intravenous injection of aqueous penicillin G at 18–24 million U/day for 10–14 days.

For patients allergic to penicillin, intravenous injection of Ceftriaxone (2 g/day) could be considered as an acceptable alternative.

Prednisolone is routinely added to prevent cord edema or Jarisch-Herxheimer reactions before the start of penicillin. After the systemic anti- syphilis treatment, the symptoms of syphilitic gumma usually disappears.

As it is extremely rare in clinical practice, almost all of the reported spinal syphilitic gumma cases are suspected as spinal tumors and are subjected to the surgery.

Surgery is surely an optimal treatment for the patients with acute spinal cord compression or whose gumma cannot be completely cured by anti-syphilis therapy.

However, high-dose penicillin therapy should be recommended first, rather than surgical treatment, for syphilis patients without neurologic deterioration who are diagnosed with NS (including the spinal syphilitic gumma) through analysis of imaging findings and laboratory examinations.

Spinal syphilitic gumma is an extremely rare manifestation of NS. Certain common MRI characteristics may contribute to the diagnosis of spinal syphilitic gumma in a syphilis–infected patient. After the diagnosis are made, instead of surgical treatment, anti-syphilitic treatment could be used to reverse the disease.

Pregnancy

Parenteral penicillin G is the only therapy with documented efficacy for syphilis during pregnancy. Pregnant women with syphilis at any stage who report penicillin allergy should be desensitized and treated with penicillin.

Jarisch-Herxheimer Reaction

The Jarisch-Herxheimer reaction is an acute febrile reaction frequently accompanied by headache, myalgia, and fever that can occur within the first 24 hours after the initiation of any syphilis therapy.

It is a reaction to treatment and not an allergic reaction to penicillin. Patients should be informed about this possible adverse reaction and how to manage it if it occurs.

The Jarisch-Herxheimer reaction occurs most frequently among persons who have early syphilis, presumably because bacterial loads are higher during these stages.