Pinta (disease)

Allysha Tan 40A

What is Pinta?

Pinta is an endemic treponematosis caused by infection with

a spirochete, Treponema carateum.

It is an ancient disease that was first described in the 16th

century in Aztec and Carib Amerindians.

In 1938, treponemes indistinguishable from those that

cause yaws and syphilis were demonstrated in lesions of a

Cuban patient.

Pinta is characterized by chronic skin lesions that occur

primarily in young adults.

Pathophysiology

Like other treponematoses, pinta is classified into an early and late stage. The early stage comprises the initial lesion and the secondary lesions, while the late stage comprises the latent phase and tertiary stage.

After an incubation period of approximately 2-3 weeks, the initial lesion appears on the skin. The primary lesion is a papule or erythematosquamous plaque usually found on exposed surfaces of the legs, dorsum of the foot, forearm, or hands. The lesion slowly enlarges and becomes pigmented and hyperkeratotic. It is often accompanied by regional lymphadenopathy.

Disseminated lesions, referred to as pintids, are similar to the primary lesion and may appear 3-9 months after infection. These secondary lesions vary in size and location and become pigmented with age.

Late or tertiary pinta is characterized by disfiguring pigmentary changes, hypochromia, achromic lesions, and hyperpigmented and atrophic lesions. The pigmentary changes often produce a mottled appearance of the skin. Lesions may appear red, white, blue, violet, and brown.

Epidemiology

Frequency

Pinta occurs in scattered foci in rural areas of Central and South America. In the 1950s, about 1 million cases of pinta were reported in Central and South America. In the 1980s, 20% seropositivity was found in remote rural areas of Panama. The current prevalence of pinta is unknown, but only a few hundred cases have been reported per year.

Mortality/Morbidity

Pinta is the most benign of the endemic treponematoses. The skin is the only organ involved.

No neurologic, bone, or cardiac manifestations occur. No congenital form exists.

Sex

Both sexes are affected with equal frequency.

Age

Pinta affects children and adults of all ages.

The peak age of incidence is 15-30 years.

Clinical Picture

The exact mode of transmission is unknown, but pinta is

probably transmitted by direct skin or mucous membrane

contact.

The initial lesion is usually found on an exposed part of the

body.

Pinta causes no constitutional symptoms.

Physical Clinical Picture

The initial lesion is a papule

that slowly enlarges to

become a pruritic plaque

Erythematosquamous plaque of

early pinta.

The dorsum of the foot and

legs are the most common

sites of lesions

Violaceous psoriatic plaque of

early pinta.

The regional lymph nodes

may enlarge.

Lesions become pigmented

with age and may change

colors from copper to grey

to slate blue.

Late pigmented pinta (blue variety).

Late lesions become

achromic or

hyperpigmented.

Causes

T carateum is the causative agent and is considered to be a

separate species from Treponema pallidum.

T carateum can be grown only in primates, and less is known

about this treponeme than any of the others.

Differential Diagnoses

Leprosy

Syphilis

Yaws

Laboratory Studies

Pinta is most often a clinical diagnosis.

The nontreponemal and treponemal serologic tests used in

diagnosing venereal syphilis are used for serodiagnosis of pinta.

Treponemes can be demonstrated by darkfield examination of

exudates from early lesions.

Nontreponemal test results (ie, rapid plasma reagent [RPR],

Venereal Disease Research Laboratory [VDRL] test) are positive

in all stages of pinta except very early lesions. Confirmatory

treponemal test results (ie, T pallidumhemagglutination [TPHA],

microhemagglutination T pallidum [MHA-TP], fluorescent

treponemal antibody absorption [FTA-Abs]) are also positive but

are not practical in remote areas.

Histologic Findings

Findings of pinta and yaws are similar, but pinta does not cause

ulcer formation.

In early lesions, mild acanthosis is present with migration of

lymphoid cells into the epidermis.

In the late stage, irregular acanthosis or epidermal atrophy

occurs.

Treponemes can be demonstrated in the epidermis in primary

and secondary lesions using silver stain.

They are absent in late achromic lesions.

Treatment

Medical Care

After penicillin therapy, lesions become

noninfectious in 24 hours.

Surgical Care

Surgery has no role in pinta treatment.

Medication

The goals of pharmacotherapy are to eradicate the infection, to

reduce morbidity, and to prevent complications.

Antibiotics

Benzathine penicillin is the drug of choice but should not be

administered to patients who are allergic to penicillin. Alternative

therapies include tetracycline or erythromycin.

Penicillin G benzathine (Bicillin LA)

Interferes with cell wall synthesis during active multiplication,

resulting in bactericidal activity against susceptible

microorganisms. Should not be administered to patients who are

allergic to penicillin.

Tetracycline (Achromycin, Sumycin)

Alternative to benzathine penicillin for patients who are allergic to

penicillin. Treats gram-positive and gram-negative organisms, as

well as mycoplasmal, chlamydial, and rickettsial infections. Inhibits

bacterial protein synthesis by binding with 30S and possibly 50S

ribosomal subunit(s).

Erythromycin (Erythrocin, E-Mycin, EES)

Indicated for the treatment of infections in children who are allergic

to penicillin or women who are pregnant. Inhibits bacterial growth,

possibly by blocking dissociation of peptidyl tRNA from ribosomes

causing RNA-dependent protein synthesis to arrest. In children, age,

weight, and severity of infection determine proper dosage. When bid

dosing is desired, one half of the total daily dose may be taken

q12h. For more severe infections, double the dose.

Follow-up

Further Inpatient Care

Lesions become noninfectious within 24 hours of treatment.

Skin lesions heal slowly.

After treatment, nontreponemal titers should decline and

eventually revert to negative.

Prognosis

The prognosis is good. The skin is the only organ affected.

Primary and secondary lesions usually heal within 6-12 months.

Pigmentary changes persist in late lesions.

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