A 31 y.o. woman presents with abdominal pain and a positive RPR at 1:16

What do you think she has?

 Arrow points to the uterus.

Arrow points to the uterus.

 View from lower in the pelvis showing the bladder.

View from lower in the pelvis showing the bladder.

Our patient had a mature teratoma with a tooth visible on the CT scan. An episode of torsion caused her pain.  Teratomas result form a germ cell retained in the ovarian tissue. The cell is totipotential and can give rise to hair bone, fat, neural tissue or even thyroid tissue. The teratoma is made up of ectoderm and mesoderm usually but when predominantly ectoderm it is called a dermoid.

Types of teratomas include:  mature (which is the predominant type), immature,  specialized teratomas i.e. thyroid tissue (struma ovarii), or fetiform teratomas. A fetiform teratoma appears to be a developing fetus without developed organs or axial skeleton.

Teratomas can be diagnosed on US when specific patterns occur but are best diagnosed on CT scan where fat can be identified within the tumor. An example of US being used to diagnose a teratoma is the dot and dash sign shown below where the ends of hair strands appear to be in dots and dashes. 

 Dot and dash sign of a teratoma.

Dot and dash sign of a teratoma.

The patient also had a positive test for syphilis.  She had numerous ED visits and several positive tests over four years but had never been treated.  Her RPR was positive  at 1:16.  As a review:

PRIMARY SYPHILIS- presents with a chancre and is present 3-90 days after exposure (average is 21 days).

SECONDARY SYPHILIS- appears 4-10 weeks after exposure and has many presentations including a rash on the palms and soles, sore throat, optic nerve involvement, liver disease, fever, and sore throat.  Symptoms resolve without treatment in 3-6 wks.

LATENT SYPHILIS- presents without symptoms and is defined as a positive serology. It is divided into early (< one year after secondary syphilis) and late (more than one year after secondary syphilis).  Our patient had latent syphilis. 

TERTIARY SYPHILIS- occurs 3-15 years after the initial infection.  One third of people develop tertiary disease without treatment. It can affect the heart (aortitis), brain (tabes dorsalis with poor balance and lightning pains in the extremities) or skin (gummas).

Our patient incidentally was found to have latent syphilis and was treated with penicillin.  An LP was done to rule out tertiary syphilis and was negative.  She had surgery and recovered without incident after her teratoma removal.

Useless trivia: The word Syphilis was coined in 1530  by an Italian poet who wrote a story about a shepherd who had the disease.  The shepherd was named Syphilis and his name came to represent the disease.

 Dark field microscopy of syphilis

Dark field microscopy of syphilis

Kent ME, Romanelli F. Reexaming syphilis: an update on epidemiology, clinical manifestations and management.2008  Annals of Pharmacotherapy 42(20 226-36.

Vinals-Iglesias H, Chimenos-Kustner E. the reappearance of a forgotten disease in the oral cavity: syphilis.2009   Medicina oral, patologia oral y cirugia buccal 14 (9): e416-20.

Dlewski J, Duong M. the rash of secondary syphilis. Canadian Medical Association Journal . 2007. 176(1):33-35.

Sahin H, Abdullazade S, Sanci M. Mature cystic teratoma of the ovary: a cutting edge overview on imaging  features.  Insights Imaging 2017 Apr;8(2):227-241.

Weiss J, Burgess J, Kaplan K. Fetiform teratoma(homunculus) Arch Pathol Lab Med. 2006;130:1552-1556.