梅毒导致抗CCP升高：一例医学模仿的病例报告

文献信息

中文摘要

引言： 苍白密螺旋体感染，即梅毒，常被称为“伟大的模仿者”，因为它倾向于出现非典型表现和非特异性症状。此外，梅毒已被证明会导致常见检测的假阳性结果，包括莱姆病、HIV和多种自身免疫性疾病。尚未被记录的一种是抗环瓜氨酸肽（抗CCP）。抗CCP是类风湿关节炎的高度特异性检测。然而，在本病例中，梅毒导致抗CCP假性升高。
病例： 一名29岁G5P3女性因3个月进行性皮疹、盗汗、寒战、淋巴结病、吞咽困难、头痛和关节痛就诊于急诊科。检查包括巨细胞病毒检测阳性以及C反应蛋白和红细胞沉降率升高。其余检测正常，她因巨细胞病毒接受对症治疗。最终，她的吞咽困难进展为无法耐受液体，促使住院。检查显示弥漫性皮疹，包括手掌和足底，以及疼痛性淋巴结病。实验室检测显示快速血浆反应素阳性，经螺旋体抗体研究确认。由于青霉素短缺，她最初接受多西环素治疗，并计划在卫生部门接受青霉素。然而，四天后她因神经系统症状返回，结果呈神经梅毒阳性，并成功接受了14天静脉青霉素疗程。在她第一次入院期间，抗CCP和抗核抗体（ANA）结果阳性，提示风湿病学病因。六个月后，随访研究显示消退，提示梅毒导致了这些升高。
结论： 二期梅毒通常与某些自身免疫标志物升高相关；然而，抗CCP通常不在其中。本病例特别值得注意，因为在没有任何风湿性疾病的情况下观察到抗CCP水平升高。与大多数二期梅毒病例一致，患者以显著的关节疼痛和肿胀为主要症状。这种临床表现，加上ANA和抗CCP阳性结果，很容易导致类风湿关节炎的误诊。如果不治疗，梅毒可能进展为神经梅毒，导致严重并发症。本病例意义重大，因为它强调了二期梅毒中一种新的医学模仿实例，临床医生必须能够识别。

英文摘要

INTRODUCTION: Infection with Treponema pallidum, or syphilis, is often called the "Great Imitator" because of its propensity for atypical presentations and non-specific symptoms. In addition, syphilis has been shown to create false-positive results for common tests, including Lyme disease, HIV, and multiple autoimmune conditions. One that has not been documented is anti-cyclic citrullinated peptide (anti-CCP). Anti-CCP is a highly specific test for Rheumatoid Arthritis. However, in this case, syphilis led to false-elevations in anti-CCP.
CASE: A 29-year-old G5P3 female presented to the emergency department with a 3-month history of progressive rash, night sweats, chills, lymphadenopathy, dysphagia, headache, and arthralgia. Work-up included a positive CMV test and elevated C-reactive protein and Erythrocyte Sedimentation Rate. Remaining tests were normal, and she was treated symptomatically for CMV. Eventually, her dysphagia progressed to an inability to tolerate liquids, prompting hospitalization. Examination showed a diffuse rash, including the palms and soles, and painful lymphadenopathy. Laboratory testing revealed positive rapid plasma reagin, confirmed by a treponemal antibody study. She was initially treated with doxycycline due to penicillin shortages, with plans to receive penicillin at the health department. However, she returned four days later with neurological symptoms and results positive for neurosyphilis and was successfully treated with a 14-day course of intravenous penicillin. During her first admission, results were positive for anti-CCP and antinuclear antibodies (ANA), suggesting a rheumatologic etiology. Six months later, follow-up studies showed resolution, suggesting syphilis caused the elevations.
CONCLUSION: Secondary syphilis is typically associated with the elevation of certain autoimmune markers; however, anti-CCP is not commonly among them. This particular case is notable due to the elevated anti-CCP level observed in the absence of any rheumatologic disease. In alignment with the majority of secondary syphilis cases, the patient presented with significant joint pain and swelling as the primary symptoms. This clinical manifestation, coupled with positive ANA and anti-CCP results, could easily result in a misdiagnosis of rheumatoid arthritis. If left untreated, syphilis may advance to neurosyphilis, leading to severe complications. This case is significant as it underscores a novel instance of medical mimicry in secondary syphilis, which clinicians must be able to identify.