• Kohei Kamegai, Shuhei Yokoyama, Shunichi Takakura, Yoshihiro Takayama, Soichi Shiiki, Hirofumi Koyama, and Masashi Narita.
• Division of Infectious Diseases, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan.
• Medicine (Baltimore). 2022 Oct 7; 101 (40): e30733e30733.

RationaleDiagnosing multifactorial, multidimensional symptoms unexplained by presumptive diagnosis is often challenging for infectious disease specialists.Patient ConcernsWe report a rare case of a 30-year-old Japanese bisexual man with a history of virally suppressed human immunodeficiency virus and syphilis infections who developed chest pain and an erosive lesion under the lower midline jaw.DiagnosisImaging examinations revealed erosive lesions on the sternum and left the ninth rib. Biopsy and polymerase chain reaction testing of sternal tissue specimens were noncontributory. However, due to elevated rapid plasma regain levels, a diagnosis of syphilitic osteomyelitis and gumma of the jaw was made.InterventionsThe patient was treated with 5 weeks of intravenous ceftriaxone and then with 8 weeks of oral amoxicillin.OutcomeAfter the antibiotic treatment, bone pain disappeared. We conducted a literature review on syphilitic osteomyelitis, and all of the articles included were case reports. Approximately half of the 46 patients with syphilitic osteomyelitis had HIV coinfection, and 10 (22%) patients lacked signs of early syphilis. Given its rarity, clinical data to establish appropriate guidelines for diagnosing and treating syphilitic osteomyelitis are still lacking. Cognitive biases, such as anchoring, cognitive overload bias, and premature closure, may contribute to diagnostic delays.LessonsIn cases of idiopathic multiple bone lesions, syphilis must always be ruled out, and clinicians should guard against cognitive pitfalls when diagnosing rare diseases.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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