Dec., 1938] EARLY ACQUIRED SYPHILIS WITH UNTREATED YAWS : RAJAM 735

Report of a case of early

ACQUIRED SYPHILIS IN A PATIENT WITH TERTIARY STIGMATA OF UN-

TREATED YAWS V

By 11. V. RAJAM, m.b., m.s., m.r.c.p.

Venereal Specialist, Government General Hospital, Madras

The relationship between syphilis and yaws still remains an unsolved problem. To the tropical venereologist, the question is really more than of academical interest. In this part of India syphilis is fairly prevalent and yaws is endemic in many of the districts of the presi- dency, and the medical man is frequently con- fronted with cases, especially in children and adolescents, in which a clear-cut diagnosis is rendered difficult or impossible. But the social and psychological importance of differentiating the two diseases looms large in the eyes of the patient. Some hold the view that yaws is only a

tropical prototype of syphilis. The Treponema pertenue of yaws is morphologically indistin- guishable from T. pallida of syphilis. Many of the clinical manifestations of the two infections are identical. Both the diseases become

systemic infections very early and the serological reaction of the blood is the same. They re- semble one another also in the rapid therapeutic response to organic arsenical drugs and bismuth

/ compounds. Yaws is said to differ from syphilis in the method of transmission of infection from the infected to non-infected, in the absence of congenital or hereditary infection, in the rarity of visceral, cardio-aortic and nervous system in- volvement, and in its strict geographical distri- bution between the Tropics of Cancer and Capri- corn. It is argued that these differences are conditioned by climate, sartorial and other social habits of the people, and by a racial peculiarity of interaction between the host and the parasite. As put forward by Stannus some years ago, an intensive comparative study, both clinical and pathological, of the two diseases under identical conditions of climate,' race, etc., is still a desi- deratum.

Others are of opinion that the two diseases are distinct and mutually exclusive. In favour of this is quoted the fact that, in regions (Pacific islands, Fiji) where yaws is rife, syphilis is rare. This is explained by the theory of a reciprocal immunity. The question of recip- rocal immunity was challenged by Neisser, von Prowazek and Castellani, who, using monkeys in experimental inoculation, declared that neither disease confers immunity to the other. But Levaditi found that monkeys immunized for yaws do not thereby acquire immunity to syphilis, but immunized for syphilis they have a partial immunity to yaws. To develop the immunity, the length of time which the infec- tion has persisted in the animal is considered important. It is suggested by Nicholls that there is a true immunity to syphilis in those persons who have suffered a long course of untreated yaws. Harrison thought that the relationship between

the two diseases would not be decided by the results of experiments to determine resistance to infection with the organism of yaws after previous inoculation with the organism of syphilis, or vice versa. It has been proved by Brown, Pearce, Chesney, Kolle and others that rabbits which have been inoculated with one strain of Treponema pallida, though resistant to that particular strain, can be successfully re- inoculated with a heterologous strain of the same organism. This experimental observation may as well be applied to the alleged absence of immunity between yaws and syphilis. The close similarity between yaws, syphilis, and the more recently described Bejel of Arabia, in their causative organisms, in their clinical manifesta- tions, serology and therapeutic response, may be explained on the supposition that they are a group of disorders of the same family (trepone- matosis). A male, aged 39 years, was admitted to the venereal

department of the Government General Hospital with a penile sore and cutaneous eruptions. Previous history.?In his 10th year the patient

developed a sore at the nape of his neck which took nearly a month to heal. From that period for about 8 years he suffered from multiple recurrent ulcers scattered all over the body, but particularly on the extremities and, from his statement, it appears that he

736 THE INDIAN MEDICAL GAZETTE [Dec., 1938

has had no special treatment for the condition. The ulcers healed and then spread. The patient finally became a cripple. Now for the past 19 years he has not suffered from any active disease. Family history.?The patient is a native of Cochin

where yaws is endemic. Unmarried. His father died when he was 16 years old. Mother alive and healthy. He has three brothers and three sisters all alive and

healthy. Present history.?Two and a half months ago he

exposed himself to the risk of venereal infection and noticed a sore on his penis 15 days after exposure. About 8 weeks after the appearance of the penile lesion he developed a rash on the skin. Condition on admission.?An ill-nourished man of 39

partly edentulous. Patient crawls about, being unable to stand and walk. Multiple, puckered, thickened scars of old ulcers on the arms, shoulder regions, buttocks, legs and feet. Both the lower extremities are badly deformed. The skin of the limbs, especially

the legs and knees, is one mass of adherent cicatricial tissue. The bones of the legs are considerably atro- phied and thin. The right foot is a shapeless mass of pseudo-elephantiasis. Both the knee joints are ankylosed in the position of partial flexion. The right hand and fingers are also deformed and scarred. The accompanying photograph reveals more than any description the state of the lower limbs. An indurated papulo-ulcerative chancre on the

anterior aspect of the coronal sulcus is partly visible in the photograph. The glands in both inguinal regions are slightly enlarged, painless and discrete. Scattered papular syphilides on the trunk and limbs. No mucous membrane or muco-cutaneous lesions. No stigmata of congenital syphilis. Dark-ground examination of the serum from the chancre showed teeming Treponema ;pallida. The Kahn and Wassermann reactions of the blood were positive. The patient was put on anti- syphilitic treatment and the chancre and cutaneous rash rapidly disappeared.

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So far as I can gather, there are not many such cases published in the literature. Hans- chell (1928) related two cases, one in a male West Indian, and the other in a West African negro, who were seen by him with primary syphilis and with serological and clinical evid- ence of old yaws. Two other cases were reported by H. D. Chambers in 1937. In the first case, a woman who had yaws ten years previously gave birth to a child with signs of congenital syphilis and had a strongly positive Wassermann reaction. The chances of the mother transmit- ting yaws were considered remote. It was in- directly inferred that the mother must have been infected with syphilis. In the second case the mother had yaws two years prior to the birth of the child. This child showed no evidence of

congenital syphilis, except that the Wassermann reaction was strongly positive.

Summary 1. A case is reported of early acquired

syphilis in a patient with tertiary stigmata of untreated yaws of 29 years' duration.

2. The patient comes from Cochin State where yaws is endemic.

3. The photograph shows the terrible crip- pling and deformity caused by untreated yaws. Such profound pathological changes in the soft tissues and bone are very unusual in syphilis.

4. The presence of long-standing yaws has not conferred any immunity against syphilis and the reaction to the syphilitic infection both local (chancre) and the cutaneous was moderately severe.

My thanks are due to the Director, Barnard Institute of Radiology, for the clinical photo- graph.

References

Chambers, H. D. (1937). Trans. Roy. Soc. Trap- Med. and Hyq., Vol. XXXI, p. 245.

Hanschell, H. M. (1928). Brit. Journ. Ven. Dls-> Vol. IV, p. 66.

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