History

Fact Explanation
Skin lesion Pinta is a chronic dermatological disease endemic to Central and South American region. It is caused by a spirochete called Treponema pallidum carateum. It is thought to spread by direct contact. Theadults. disease is more common among young adults. Patients may encounter small raised bumps (Papules) which enlarge slowly at initial stage. Exposed areas of dorsum of the foot, the legs, hands or forearms are commonly affected. The raised bump becomes itchy, red and scaly and eventually a pigmented firmer (hyperkeratotic) and flat lesion (Plaque). Usually after 3-6 months (or up to 3 years) from the initial presentation further thickened and flat lesions (pintids) appear all over the body. They show abnormal pigmentation and scaling. Lesions may appear red, white, blue, violet, or brown.Initial papules and pintids may resolve with time in a majority of patients. But some patients develop late-stage disease, characterised by widespread mixture of hyperpigmentation and depigmentation. These lesions may appear red, white, blue, violet, and brown and often disfiguring. The affected skin become atrophic and thin. [1,2,3,4,5]
References
  1. GIULIANI M, LATINI A, PALAMARA G, MAINI A, DI CARLO A. The clinical appearance of pinta mimics secondary syphilis: another trap of treponematosis? Clin Infect Dis [online] 2005 May 15, 40(10):1548; author reply 1548-9 [viewed 25 July 2014] Available from: doi:10.1086/429726
  2. MARQUEZ F, REIN CR, ARIAS O. Not Available Bull World Health Organ [online] 1955, 13(2):299-322 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13260889
  3. DE CAPRARIIS PJ, DELLA-LATTA P. Serologic cross-reactivity of syphilis, yaws, and pinta. Am Fam Physician [online] 2013 Jan 15, 87(2):80 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23317070
  4. ROTHSCHILD B. Pinta: specific disease or anomalous skin reaction? Clin Infect Dis [online] 2005 Sep 15, 41(6):914 [viewed 25 July 2014] Available from: doi:10.1086/432805
  5. MITJà O, ŠMAJS D, BASSAT Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis [online] 2013, 7(10):e2283 [viewed 25 July 2014] Available from: doi:10.1371/journal.pntd.0002283

Examination

Fact Explanation
Primary pinta (Papules and plaques) This is composed of several papules to hyperkeraotic, pigmented plaque in exposed areas such as legs, dorsum of foot, forearm and hands. [1,2,3]
Secondary pinta (Pintids) Abnormally pigmented, thickened plaques with red, white, blue, violet, or brown colors may appear all over the body including unexposed areas. [1,2,3]
Tertiary pinta This is characterized by disfiguring hypo/hyperpigmentations all over the body. [1,2,4,5]
Lymphadenopathy Regional lymph node enlargement may occur from the primary stage. [1,2]
References
  1. GIULIANI M, LATINI A, PALAMARA G, MAINI A, DI CARLO A. The clinical appearance of pinta mimics secondary syphilis: another trap of treponematosis? Clin Infect Dis [online] 2005 May 15, 40(10):1548; author reply 1548-9 [viewed 25 July 2014] Available from: doi:10.1086/429726
  2. DE CAPRARIIS PJ, DELLA-LATTA P. Serologic cross-reactivity of syphilis, yaws, and pinta. Am Fam Physician [online] 2013 Jan 15, 87(2):80 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23317070
  3. MARQUEZ F, REIN CR, ARIAS O. Not Available Bull World Health Organ [online] 1955, 13(2):299-322 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13260889
  4. ROTHSCHILD B. Pinta: specific disease or anomalous skin reaction? Clin Infect Dis [online] 2005 Sep 15, 41(6):914 [viewed 25 July 2014] Available from: doi:10.1086/432805
  5. MITJà O, ŠMAJS D, BASSAT Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis [online] 2013, 7(10):e2283 [viewed 25 July 2014] Available from: doi:10.1371/journal.pntd.0002283

Differential Diagnoses

Fact Explanation
Syphilis An infectious venereal disease following Treponema pallidum infection. The primary route of transmission is through sexual contact; it may also be transmitted from mother to fetus during pregnancy or at birth, resulting in congenital syphilis. Presentation of syphilis varies and mimics several diseases. So it is describes as four different stages: primary, secondary, latent, and tertiary. Symptoms of syphilis begin with a painless but highly infectious sore on the genitals, or sometimes around the mouth. Secondary symptoms, such as a skin rash and sore throat, then develop. Around a third of people who are not treated for syphilis will develop tertiary syphilis. At this stage, it can cause serious organ damages. [1,3]
Leprosy A chronic infection caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis. The main symptom of leprosy is disfiguring skin sores, lumps, or bumps that do not go away after several weeks or months. The skin sores are pale-colored. Nerve damage can lead to loss of feeling in the arms and legs and muscle weakness. [2]
Yaws The most prevalent infectious and nonvenereal treponemal disease caused by Treponema pallidumpertenue with the initial stage characterized by the appearance of small, painless bumps on the skin that group together and grow until they resemble a strawberry. A crispy and crunchy rash that covers arms, legs, buttocks and/or face is a late sign. [3]
References
  1. PATTON ME, SU JR, NELSON R, WEINSTOCK H, CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC). Primary and secondary syphilis--United States, 2005-2013. MMWR Morb Mortal Wkly Rep [online] 2014 May 9, 63(18):402-6 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24807239
  2. KUMAR B, DOGRA S. Leprosy: a disease with diagnostic and management challenges! Indian J Dermatol Venereol Leprol [online] 2009 Mar-Apr, 75(2):111-5 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19293495
  3. MITJà O, ŠMAJS D, BASSAT Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis [online] 2013, 7(10):e2283 [viewed 25 July 2014] Available from: doi:10.1371/journal.pntd.0002283

Investigations - for Diagnosis

Fact Explanation
Dark field microscopy Treponemes can be demonstrated from swabs taken from early papules. [1,2]
Treponema pallidum particle agglutination assay (TPPA) TPPA is a confirmatory treponemal test and an indirect agglutination assay used for detection and titration of antibodies against Treponema pallidum. This is also positive in pinta. [1,2,3]
Venereal Disease Research Laboratory (VDRL) test This is a widely used as a nontreponemal serological screening for syphilis. But this is positive in pinta. [3,4,5]
Rapid plasma reagent (RPR) It is a rapid diagnostic test that looks for non-specific antibodies for Treponema pallidum species. RPR is always positive in pinta from the initial stage. [3,4,5]
Histology Biopsy of the lesions may reveal characteristic microscopic changes such as mild acanthosis, migration of lymphoid cells into the epidermis and epidermal atrophy eventually. In early lesions, treponemes may be demonstrated using silver stain. [1,2,5]
References
  1. GIULIANI M, LATINI A, PALAMARA G, MAINI A, DI CARLO A. The clinical appearance of pinta mimics secondary syphilis: another trap of treponematosis? Clin Infect Dis [online] 2005 May 15, 40(10):1548; author reply 1548-9 [viewed 25 July 2014] Available from: doi:10.1086/429726
  2. MARQUEZ F, REIN CR, ARIAS O. Not Available Bull World Health Organ [online] 1955, 13(2):299-322 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13260889
  3. MITJà O, ŠMAJS D, BASSAT Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis [online] 2013, 7(10):e2283 [viewed 25 July 2014] Available from: doi:10.1371/journal.pntd.0002283
  4. DE CAPRARIIS PJ, DELLA-LATTA P. Serologic cross-reactivity of syphilis, yaws, and pinta. Am Fam Physician [online] 2013 Jan 15, 87(2):80 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23317070
  5. ROTHSCHILD B. Pinta: specific disease or anomalous skin reaction? Clin Infect Dis [online] 2005 Sep 15, 41(6):914 [viewed 25 July 2014] Available from: doi:10.1086/432805

Management - Specific Treatments

Fact Explanation
Antibiotics Benzathine penicillin is the drug of choice However this should not be given to patients those who are allergic to penicillin. Tetracycline or erythromycin are the alternative therapies for such patients. Skin lesions become non-infectious within 24 hours of treatment. Early lesions heal within 6 to 12 months, but pigmentary changes persist in late lesions. [1,2,3]
References
  1. MARQUEZ F, REIN CR, ARIAS O. Not Available Bull World Health Organ [online] 1955, 13(2):299-322 [viewed 25 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/13260889
  2. ROTHSCHILD B. Pinta: specific disease or anomalous skin reaction? Clin Infect Dis [online] 2005 Sep 15, 41(6):914 [viewed 25 July 2014] Available from: doi:10.1086/432805
  3. MITJà O, ŠMAJS D, BASSAT Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis [online] 2013, 7(10):e2283 [viewed 25 July 2014] Available from: doi:10.1371/journal.pntd.0002283