Dermatology: Practical and Conceptual


Image Letter | Dermatol Pract Concept. 2023;13(4):e2023210 1

“Snail-Track Ulcers” And Macroglossia 
Due to Secondary Syphilis

Alba Navarro-Bielsa1, Tamara Gracia-Cazaña1, Yolanda Gilaberte1

1 Department of Dermatology, Miguel Servet University Hospital, IIS Aragón, Zaragoza, Spain

Citation: Navarro-Bielsa A, Gracia-Cazaña T, Gilaberte Y. “Snail-Track Ulcers” And Macroglossia Due To Secondary Syphilis. Dermatol 
Pract Concept. 2023;13(4):e2023210. DOI: https://doi.org/10.5826/dpc.1304a210

Accepted: March 18, 2023; Published: October 2023

Copyright: ©2023 Navarro-Bielsa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, 
distribution, and reproduction in any medium, provided the original authors and source are credited.

Funding: None.

Competing Interests: None.

Authorship: All authors have contributed significantly to this publication.

Corresponding Author: Alba Navarro-Bielsa, Department of Dermatology, Hospital Miguel Servet, Paseo Isabel la Católica, 1-3, 
Zaragoza 50009, Spain. Telephone: (+34) 976 76 55 00 E-mail: albanavarrobielsa@hotmail.com

Case Presentation

A 36-year-old woman was referred to the Dermatology 

department for painful ulcers on the tongue and macro-

glossia (Figure 1A). Oral findings showed scattered depa-

pilation and moist ulcers, irregular linear erosions termed 

‘snail-track’ ulcers on the dorsum of the tongue and the 

left margin.

A PCR was performed for viruses and bacterias and the 

diagnosis of secondary syphilis was reached by a positive 

Treponema pallidum PCR on a tongue swab and a positive 

syphilis serology (RPR and TPPA test). The lesions com-

pletely resolve with benzathine penicillin G 2.4 million units 

treatment in one month (Figure 1B).

Teaching Point

Oral lesions are presented in at least 30% of patients with 

secondary syphilis, although oral ulceration is rarely pre-

sented as the only manifestation of infection [1]. The most 

common oral features of secondary syphilis are mucous 

patches and maculopapular lesions [1,2].

The oral features of secondary syphilis can be painless or 

painful erythematous lesions, grayish-white mucous patches 

or, less frequently, irregular linear erosions (snail track 

 ulcers)  [2]. We describe a case diagnosed of syphilis with 

 significant involvement of the tongue with snail-track ulcers, 

which are not common but could be a diagnostic clue, which 

evidence the need for considering syphilis in the differential 

diagnosis of oral ulcerations.



2 Image Letter | Dermatol Pract Concept. 2023;13(4):e2023210

References

1. de Andrade RS, de Freitas EM, Rocha BA, Gusmão ES, 

Filho MR, Júnior HM. Oral findings in secondary syphilis. Med 

Oral Patol Oral Cir Bucal. 2018;23(2):e138-e143. DOI: 10.4317 

/medoral.22196. PMID: 29476680. PMCID: PMC5911365.

2. de Oliveira Alves A, Filho FB. Snail track ulcers of the tongue. Pan 

Afr Med J. 2018;30:23. DOI: 10.11604/pamj.2018.30.23.14118. 

PMID: 30167051. PMCID: PMC6110555.

Figure 1. (A) Clinical image of the tongue before the treatment, with “snail-track ulcers”,  depapilation 

and macroglossia. (B) Clinical image of the tongue 1 month after the treatment, with resolution of 

the lesions.