Snail track ulcer

A 40-year-old promiscuous male presented to our outpatient department with complaints of whitish lesion over the soft palate for the past 2 weeks. The lesion was completely asymptomatic and he had a history of genital ulcer 3 months back which healed spontaneously without any treatment. He was oriented bisexually and had multiple unprotected anal or oral coitus with multiple partners. The genital examination was normal and the oral cavity revealed a single whitish serpiginous track with erythematous border over the soft palate [Figure 1]. The patient had no lymphadenopathy, fever, or any skin lesions and the systemic examinations were within normal limits. The rapid plasma reagin was reactive in 1:32 dilution and treponema pallidum hemagglutination assay was also reactive. The serology for herpes simplex virus 1 and 2 and human immunodeficiency virus 1 and 2 was non-reactive. Hence, a diagnosis of secondary syphilis with mucosal snail track ulcer was made and the patient was treated with a single dose of injection benzathine penicillin 2.4 million units intramuscularly. Proper counseling has been given and partner tracing could not be done as he had multiple male and female partners. After 2 months, the lesion started resolving and the patient was in regular follow-up [Figure 2].

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Figure 1:

Whitish serpiginous track in the soft palate.

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Figure 2:

The lesion starts resolving after treatment.

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Secondary syphilis is known as a great imitator, presents with florid mucocutaneous manifestations. In about one-third of the total cases, the oral cavity can be involved.^[1] They can present like an elevated plaque or numerous mucous patches that coalesce to give rise to a serpiginous lesions, called as “snail-track ulcers.” This case highlights the manifestation of secondary syphilis in oral cavity in the absence of lesions elsewhere in the body. The occurrence of oral lesions in the absence of skin lesions makes the diagnosis difficult and in such cases, it is based on the relevant history and the positive serological tests.