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Pinta

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Pinta is a chronic disfiguring skin disease of Central and South America, caused by infection with the bacterium Treponema carateum.


Presentation

Pinta is a chronic disease that only affects the skin. It is seen most commonly in young adults. Pinta, like other endemic treponematoses, progresses along defined disease stages. There is an early stage and a late stage. The early stage is divided into primary and secondary stages. Individuals may stop at the early stage or progress onto a late stage, with disfiguring tertiary lesions. Symptoms and progression vary in different individuals [5].

The primary stage consists of the initial lesions. Symptoms may appear as early as seven days after infection, although the incubation period is usually 2-3 weeks [6]. There may be one or more papules that appear on the skin. The areas commonly affected are the exposed skin surfaces – the tops of the feet, the legs, the backs of the hands, and the forearms. However, other areas may also be involved, such as the face, neck, or abdomen. These papules are erythematous and pruritic. The papules slowly enlarge to form large flatter, pigmented, and firm, scaly, hyperkeratotic lesions, known as plaques. The lymph nodes near the affected show regional lymphadenopathy. However, the patient does not develop systemic disease [1] [3] [7] [9].

A second stage occurs around 1-6 months (or in some cases up to three years) after the initial infection. In this second stage, there is a widespread disseminated eruption of secondary lesions over the skin. These secondary lesions are called pintids. Pintids are large, flat, scaly, itchy plaques. They usually start red and become pigmented (to brown or slate-blue) with age. The secondary lesions can persist for years, and are infectious. Pintids can recur for up to 10 years [8].

In most patients, the initial papules and pintids resolve with time. However, some people may go on to develop late-stage disease. Late stage disease occurs about 2-5 years after the initial infection. In late stage disease, the secondary lesions develop into tertiary lesions. The secondary lesions lose their pigment and the skin becomes atrophic. Patients with late stage pinta have a mixture of lesions with varying degrees of depigmentation and thinning. Some lesions may be hyperpigmented, some hypochromic (low levels of pigment), and some achromic (no pigment). The pigmentary changes often produce a disfiguring mottled appearance to the skin, with lesions ranging from red to white, blue, violet, or brown [1] [3] [7] [9].

Physician
  • Because of the influx of migrants and refugees from Latin America, U.S. physicians should consider pinta in the differential diagnosis of skin diseases in children and adolescents who come from areas where pinta was previously endemic and have a positive[ncbi.nlm.nih.gov]
  • Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians[emedicine.medscape.com]
  • , American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, Massachusetts Medical Society Disclosure: Nothing to disclose.[emedicine.medscape.com]
  • , American College of Physicians , American Medical Association , American Society for Microbiology , Infectious Diseases Society of America , Massachusetts Medical Society Disclosure: Nothing to disclose.[emedicine.medscape.com]
  • Dermatologist —A physician that specializes in diseases and disorders of the skin. Resources BOOKS Desowitz, Robert S. Who Gave Pinta to the Santa Maria?: Torrid Diseases in a Temperate World San Diego: Harcourt Brace, 1998 Weinberg, Samuel, Neil S.[healthofchildren.com]
Weakness
  • Seronegative controls demonstrated only weak reactivity to fewer than five molecules.[ncbi.nlm.nih.gov]
Ulcer
  • Nigerian boy with ulcerative skin lesions characteristic of yaws. Courtesy of the CDC/Dr. Lyle Conrad. Photomicrograph (540X) of Treponema carateum obtained from an early pinta lesion. Courtesy of the CDC.[emedicine.medscape.com]
  • The papule or plaque, which is teeming with infectious treponemes, does not ulcerate, but expands to a diameter of 10 cm or greater. Regional lymphadenopathy is common.[ncbi.nlm.nih.gov]
Hyperpigmentation
  • These generally resolve, but a proportion of people with pinta will go on to develop late-stage disease, characterised by widespread pigmentary change with a mixture of hyperpigmentation and depigmentation which can be disfiguring. [2] Pinta is usually[en.wikipedia.org]
  • This creates a mottled appearance to the skin, with pintids in varying stages of hyperpigmentation, hyperkeratisation, depigmentation, or thinning.[symptoma.com]
Thin Skin
  • This creates a disfiguring appearance, consisting of mottling, with areas of thicker, hyperpigmented skin intermingled with hypopigmented, thin skin. This stage lasts years. The disease is readily treatable with injectable long acting penicillin.[symptoma.com]
Skin Atrophy
  • ., from dyschromic treponeme-containing lesions to achromic treponeme-free lesions), skin atrophy, and hyperkeratosis. 1 – 3 The degree of lesion pigmentation can be different in the same patient, resulting in a mottled appearance of the skin, which can[ncbi.nlm.nih.gov]
Neglect
  • Abstract Pinta is a neglected, chronic skin disease that was first described in the sixteenth century in Mexico. The World Health Organization lists 15 countries in Latin America where pinta was previously endemic.[ncbi.nlm.nih.gov]
  • The endemic treponematoses, pinta, yaws, and bejel, are caused by spiral-shaped, not-yet-cultivable bacteria of the genus Treponema . 1 – 3 These neglected infectious diseases (NIDs), for which there are no vaccines, present a diagnostic dilemma to physicians[ncbi.nlm.nih.gov]
Forgetful
  • Of course, as the accolades pour in for Azul's cuisine, let's not forget about satisfying your thirst. With swim-up bars, themed bars brimming with top shelf brands and wine selections, the pleasures of premium drinks need never run dry.[karismahotels.com]

Workup

Commercially available laboratory testing is unable to distinguish infection with Treponema carateum from infection with the other Treponema species that cause the diseases yaws, endemic syphilis, and venereal syphilis. Serological tests will indicate a Treponema spirochete infection but will not be able to identify with which one [3] [8].

The spirochete itself, the infectious Treponemes, may be seen using dark-field microscopy, using swabs taken from the primary and secondary lesions. The spirochetes may also be seen using silver staining upon histopathological examination of biopsy specimens of the primary and secondary lesions. These Treponemes are identical in appearance to the other Treponema species. A positive identification will indicate a Treponema spirochete infection but will not be able to identify which one [8].

A biopsy of the lesions may reveal characteristic microscopic changes. However, pinta is usually diagnosed based on identification of Treponema spirochetes, the appearance and distribution of the lesions (affecting the skin only), and a history of having lived or traveled in endemic areas [8].

Treponema Carateum
  • An infectious disease of the skin caused by treponema carateum that occurs only in the western hemisphere. Age of onset is between 10 and 20 years of age.[icd9data.com]
  • Pinta occurs when the bacterium, Treponema carateum, infects open wounds and sores. Treponema carateum is a type of bacteria called a spirochete.[symptoma.com]
  • A contagious skin disease prevalent in tropical America, caused by a spirochete (Treponema carateum) and marked by extreme thickening and spotty discoloration of the skin. pinta [pēn′tə] Etymology: Sp, spot an infection of the skin caused by Treponema[medical-dictionary.thefreedictionary.com]
  • The development of antibody reactivity to the full spectrum of T. pallidum antigens during the course of infection demonstrates the high degree of antigenic relatedness of T. pallidum and Treponema carateum and is similar to the development of humoral[ncbi.nlm.nih.gov]
  • The etiological agent of pinta, Treponema carateum, cannot be distinguished morphologically or serologically from the not-yet-cultivable Treponema pallidum subspecies that cause venereal syphilis, yaws, and bejel.[ncbi.nlm.nih.gov]
Treponema Carateum
  • An infectious disease of the skin caused by treponema carateum that occurs only in the western hemisphere. Age of onset is between 10 and 20 years of age.[icd9data.com]
  • Pinta occurs when the bacterium, Treponema carateum, infects open wounds and sores. Treponema carateum is a type of bacteria called a spirochete.[symptoma.com]
  • A contagious skin disease prevalent in tropical America, caused by a spirochete (Treponema carateum) and marked by extreme thickening and spotty discoloration of the skin. pinta [pēn′tə] Etymology: Sp, spot an infection of the skin caused by Treponema[medical-dictionary.thefreedictionary.com]
  • The development of antibody reactivity to the full spectrum of T. pallidum antigens during the course of infection demonstrates the high degree of antigenic relatedness of T. pallidum and Treponema carateum and is similar to the development of humoral[ncbi.nlm.nih.gov]
  • The etiological agent of pinta, Treponema carateum, cannot be distinguished morphologically or serologically from the not-yet-cultivable Treponema pallidum subspecies that cause venereal syphilis, yaws, and bejel.[ncbi.nlm.nih.gov]
Treponema Pallidum
  • Sera were evaluated for antibody to individual Treponema pallidum antigens.[ncbi.nlm.nih.gov]
  • The etiological agent of pinta, Treponema carateum, cannot be distinguished morphologically or serologically from the not-yet-cultivable Treponema pallidum subspecies that cause venereal syphilis, yaws, and bejel.[ncbi.nlm.nih.gov]
  • Genetic diversity in Treponema pallidum: Implications for pathogenesis, evolution and molecular diagnostics of syphilis and yaws. Infect Genet Evol . 2011 Dec 15. [Medline] .[emedicine.medscape.com]
  • Bejel, yaws (frambesia), and pinta are infections caused by bacteria (called treponemal spirochetes) that are closely related to Treponema pallidum, which causes the sexually transmitted disease syphilis.[merckmanuals.com]
  • Moreover, serological tests cannot differentiate the endemic treponematoses from each other or from venereal syphilis, which is caused by the closely related spirochete, Treponema pallidum subspecies pallidum .[ncbi.nlm.nih.gov]
Gram-Positive Bacteria
  • Effective against gram-negative and gram-positive bacteria. Well-absorbed from GI tract and metabolized in the liver, where it is inactivated by conjugation with glucuronic acid and then excreted by the kidneys. Smajs D, Norris SJ, Weinstock GM.[emedicine.medscape.com]

Treatment

The treatment of choice for pinta is a once-off intramuscular injection of long-acting benzathine penicillin. This one off injection is curative [6]. For those that are allergic to penicillin, erythromycin or tetracyclines are alternatives [1] [8] [10].

Prognosis

The prognosis is good if treatment is given early in the disease. About 24 hours after treatment, the individual is no longer infectious to others. Treatment will kill all the bacteria and result in a complete cure. The skin lesions will slowly heal over 6-12 months. If an individual has late stage disease, treatment will eliminate the bacteria but any chronic skin changes are usually irreversible. There is a poor prognosis if the lesions have spread to the eye region and cause irreversible eyelid deformities.

Etiology

Pinta occurs when the bacterium, Treponema carateum, infects open wounds and sores. Treponema carateum is a type of bacteria called a spirochete. It is morphologically and serologically identical to the spirochetes that cause yaws, endemic syphilis, and venereal syphilis [1] [3]. As it is thought to be spread by direct contact, poor hygiene likely plays a key role in its spread.

Epidemiology

Pinta is a disease endemic to rural and remote pockets of Central and northern South America [4]. It does not occur in the United States. The incidence of pinta in Central and South America may be decreasing. In the 1950s, there were about one million cases across this area and, in the 1980s, 20% of people in rural and remote villages of Panama tested positive for antibodies to Treponema. Although the exact current prevalence of pinta is unknown, in recent years, only a few hundred cases per year have been reported [5] [6]. Pinta occurs in people of all ages, although the peak incidence of occurrence is in people aged 15 to 30 years [6] [7].

Sex distribution
Age distribution

Pathophysiology

Pinta is one of three endemic treponematosis. The causal infectious agent of pinta, Treponema carateum, is a spirochete. The other endemic treponematoses are yaws and endemic syphilis, which are caused by subspecies of the spirochete Treponema palladium. Another subspecies, Treponema palladium subspecies palladium, causes venereal syphilis. All these spirochetes are indistinguishable in appearance and there is no serological test to distinguish infection by one from the other [3]. These spirochetes are difficult to culture and it has been difficult to create animal models for pinta. For this reason, the exact pathophysiology is not well understood [1] [7].

It is thought that spread is by direct skin-to-skin contact. The primary and secondary skin lesions of affected individuals are infectious. It is believed the bacteria enter the skin through cracks or sores in the skin.

Like all the treponematoses, pinta has primary, secondary, and tertiary lesions, and periods of latency. It is classified into early and late stages of presentation. The early stage consists of primary and secondary lesions and may last for years. The primary lesions (papules) occur where the bacteria initially enter the skin and typically appear 2-3 weeks after initial infection. They continue to enlarge, and thicken and darken to form plaques. The local lymph nodes may also enlarge but they are usually painless. Secondary satellite lesions (pintids) occur some months later, caused by spread of the bacteria to other areas of the skin. This is presumably aided by scratching the itchy primary lesions, although the exact methods of spread are unknown. The pintids become thicker and darker with age  [1] [7].

The body may destroy the bacteria and the lesions may regress. Some individuals may maintain a latent infection, with no skin lesions, yet they will still show up positive on serological tests [8]. After a period of years, some individuals may develop tertiary disease. Pintids keep appearing or persist. Over time, the lesions lose their pigment and the skin becomes thin. This creates a mottled appearance to the skin, with pintids in varying stages of hyperpigmentation, hyperkeratisation, depigmentation, or thinning [1] [7].

Prevention

It is thought that pinta is spread by direct contact with an infectious primary or secondary lesion, with the bacteria getting in through a cut or a scratch on the skin. Good personal hygiene by both the person who has the lesion and all people who are in contact may help prevent its spread. The most vulnerable population, children and young adults, should minimize their contact with infected individuals. Early prompt treatment can eliminate its spread, with individuals being no longer infectious within 24 hours of treatment.

Summary

Pinta is a chronic skin disease endemic to rural and remote areas of tropical Central and northern South America. It is caused by a species of spirochete bacterium called Treponema carateum [1] [2]. Infection more commonly occurs in young adults. The bacterium is most likely spread by direct skin-to-skin contact from the infectious sores of an affected individual. The bacteria gets in through cuts or scratches on the skin surface, so the initial lesions usually occur on exposed surfaces, such as the legs, arms, hands, and feet.

Pinta is known as an endemic treponematosis. Other endemic treponematoses are yaws and endemic syphilis, which are caused by two subspecies of the spirochete bacteria Treponema Palladium. The bacteria that cause pinta and these other diseases are all morphologically identical and are indistinguishable on serological tests. They are also indistinguishable from the spirochete, Treponema Palladium subspecies Palladium, which causes venereal syphilis [1] [3].

Pinta is the most benign of the treponematoses, in that it affects only the skin and causes no systemic illness. A treponematosis can be diagnosed by recognition of the characteristic spirochete bacteria by dark field microscopy and using serological tests. However, the different treponemoses are only distinguishable from each other based on the location of the lesions (if skin only or involving other organs), the mode of transmission, and their endemic geographical location.

Like all the treponematoses, pinta is a multi-stage disease. All the treponematoses have early and late stages to the disease. The early stage consists of a primary and a secondary stage. There may be a period of latency, followed by the late phase, which consists of tertiary lesions [1].

The primary stage of pinta consists of the primary skin lesion/s, which begin as papules which turn into itchy red plaques. This stage lasts for several months and is followed and sometimes overlapped by a second stage, which consists of a more widespread eruption across the skin of hyperpigmented, hyperkeratotic plaques, called pintids. This stage lasts months to years. In some patients, these plaques regress and the disease does not progress further. However, for some patients, after a time, they go on to develop tertiary stage disease, where the plaques lose their pigment and the skin becomes thinner. This creates a disfiguring appearance, consisting of mottling, with areas of thicker, hyperpigmented skin intermingled with hypopigmented, thin skin. This stage lasts years [1].

The disease is readily treatable with injectable long acting penicillin. Even when cured, the chronic changes of late stage disease are often irreversible [1].

Patient Information

Pinta is a skin disease that occurs in isolated pockets of tropical central and South America, in places such as Peru and Panama. It is caused by a bacteria called Troponema carateum. Pinta causes itchy sores on the skin. These sores are infectious. The bacteria from these sores can be spread to another person by touch. They get into the skin through cracks and scratches on the skin.

The disease occurs in stages. When a person first get the disease, they develop itchy red scaly bumps on the surface of the skin. These bumps usually appear about 2-3 weeks after the initial infection and slowly get bigger over months. They form into a large thickened scaly raised area, called a plaque. These initial bumps usually occur where the bacteria first enter the skin, usually on the arms, legs, or face.

After a period of many months, more sores appear on the skin around the initial bump and elsewhere on the body. The lymph nodes nearby may enlarge but they are painless. These new sores have a different appearance to the initial ones. They are flat areas of thickened, itchy skin. They are called pintids. They start off red and get darker, becoming blue, brown, or black with time. Eventually, over months to years, these pintids get lighter and thinner and may disappear.

In some people, pintids keep appearing over many years and persist. The skin takes on a disfiguring mottled appearance. Patients have areas of skin that are thickened and darker intermingled with areas that have no pigment and where the skin is very thin.

The bacteria that causes pinta is very similar to the bacteria that causes two other skin diseases, yaws and endemic syphilis. It is also similar to the bacteria that causes the sexually transmitted syphilis. In fact, the different bacteria that cause these diseases look identical and current standard tests are unable to distinguish infection by one from the other. The only way to identify pinta from the other diseases is to look at the appearance and location of the skin sores, see that it is affecting only the skin, and look to see what geographical area the person has come from.

The disease is easily treatable with a single injection of penicillin. Although the injection will kill the bacteria, if a person already has long-term disfiguring skin changes, these skin changes will often be permanent.

References

Article

  1. Marquez F, Rein CR, Arias O. Mal del pinto in Mexico. Bull World Health Organ. 1955; 13(2):299-322.
  2. Chulay JD. Treponema Species (Yaws, Pinta, Bejel). Mandell, Douglas, Bennett eds. Principles and Practice of Infectious Diseases. 5th ed. Philadelphia, Pa: Churchill Livingstone; 2000; (2)2490-2494.
  3. De Caprariis PJ, Della-Latta P. Serologic cross-reactivity of syphilis, yaws, and pinta. Am Fam Physician. 2013; 87(2):80.
  4. Woltsche-Kahr I, Schmidt B, Aberer W, et al. Pinta in Austria (or Cuba?): import of an extinct disease?. Arch Dermatol. 1999; 135(6):685-688.
  5. Engelkens HJ, Vuzevski VD, Stolz E. Nonvenereal treponematoses in tropical countries. Clin Dermatol. 1999; 17(2):143-152; discussion 105-106.
  6. Lupi O, Madkan V, Tyring SK. Tropical dermatology: bacterial tropical diseases. J Am Acad Dermatol. 2006; 54(4):559-578.
  7. Parish JL. Treponemal infections in the pediatric population. Clin Dermatol. 2000; 18(6):687-700.
  8. Mitjà O, Smajs D, Bassat Q. Advances in the diagnosis of endemic treponematoses: yaws, bejel, and pinta. PLoS Negl Trop Dis. 2013; 7(10):e2283.
  9. Giuliani M, Latini A, Palamara G, et al. The clinical appearance of pinta mimics secondary syphilis: another trap of treponematosis? Clin Infect Dis. 2005; 40(10):1548; author reply 1548-1549.
  10. Rothschild B. Pinta: specific disease or anomalous skin reaction? Clin Infect Dis. 2005; 41(6):914.

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Last updated: 2019-07-11 22:54