1. Case Presentation Jung Hyun Seo Department of Internal Medicine Catholic University of Daegu School of Medicine School of Medicine

2. ► C/C: Postprandial epigastric pain for 2 months ► Present Illness: 37/M Presented with postprandial epigastric pain and weight loss of 8kg over past 6 months. Presented with postprandial epigastric pain and weight loss of 8kg over past 6 months. Previous EGD and biopsy has shown benign gastric ulcer. Previous EGD and biopsy has shown benign gastric ulcer. Follow-up EGD after 1 month of antiulcer medication revealed enlarged gasric ulcer. Follow-up EGD after 1 month of antiulcer medication revealed enlarged gasric ulcer. He was referred to us for further evaluation & management. He was referred to us for further evaluation & management. ► Past medical history: DM/HTN/TBc/Liver disease (+/-/-/-) DM/HTN/TBc/Liver disease (+/-/-/-) ► Family history: Unremarkable ► Social history: Alcohol- 소주 1 병 2 회 /week Alcohol- 소주 1 병 2 회 /week Smoking- 15 packyears Smoking- 15 packyears

3. Review of systems GeneralFever (-), Chill (-), Weakness (-), Fatigue (-) Weight change(-) SkinSkin rash (-), Pruritus (-), Mass (-), Jaundice (-) HEENTHeadache (-), Vertigo (-), Tinnitus (-), Diplopia (-) Rhinorrhea (-), Sore throat (-) Cardio-pulmonaryCough (-), Sputum (-), Dyspnea on exertion (-), Orthopnea(-), Chest pain(-), Palpitation (-) GITAnorexia/Nausea/Vomiting/Diarrhea/Constipation (+/+/-/-/-) GUTOliguria (-), Polyuria (-), Nocturia (-), Hematuria (-), Urgency (-), Voiding difficulty (-) Neuro-muscularSyncope(-), Dizziness(-), Weakness(-), Pain(-) Arthralgia(-), Bone pain(-)

4. Physical examination ► ► Vital signs ► ► HEENT not anemic conjunctivae anicteric sclerae no palpable neck mass no palpable LN ► ► Lung clear breathing sounds without crackles ► ► Heart regular with no murmur ► ► Abdomen soft & flat, normoactive bowel sound tenderness at epigastric area no hepatosplenomegaly ▶ ▶ Extremity no pretibial pitting edema

5. Laboratory findings CBC 7,600 (PMNL 64.1%) -11.7- 496,000 AST/ALT 15/2 IU/L ALP/GTP 144/12 IU/L T-bilirubin 0.2 mg/dl Amylase/Lipase 77/65 U/l LDH 248 IU/L TG/T-Chol 126/168 mg/dl Protein/Albumin 6.3/3.1 g/dl BUN/Cr 9.0/0.8 mg/dl Na/K 134/4.0 mEq/L Ca/P 8.9/4.3 mg/dl VDRL (-) Glucose 312 mg/dl Hb A 1 C 9.8%

6. EGD

7. Abdomino-Pelvic CT

8. EUS

9. Biopsy

10. Hospital Course ► ► Discharged and Follow up in outpatient clinic after 1 week. ► ► Physical Exam: palpable inguinal lymph node ► ► Re-admission for inguinal lymph node biopsy   Reactive hyperplasia ► ► History taking: genital ulcer Hx. before 5 months. Coitus Hx. ► ► VDRL: positive ► ► TPHA: 1:10,240 ► ► FTA-ABS IgM/IgG reactive/reactive ► 2.4 million units IM injection weekly for 3 weeks ► Benzathine penicillin G 2.4 million units IM injection weekly for 3 weeks ► Slight improvement of symptoms

11. Follow- up EGD after 1 month

12. EGD after 8 month

13. Final Diagnosis Gastric syphilis

14. Review ► Rare manifestation of the secondary and tertiary forms of the disease, which may affect young adults. ► Very difficult to make a definitive diagnosis of gastric syphilis on the basis of biopsy findings ► Diagnosis from retrospective review of data  Biopsy is negative for cancer  Serologic tests are positive for syphilis  Gastric lesion resolves after therapy with penicillin ► Difficult to differentiate from gastric cancer ► Complications: hemorrhage and perforation Chen et al. J Clin Microbio 2006 Madding et al. Ann Surg 1964