Stages of syphilis
Natural history of untreated syphilis. Rebecca E. LaFond and Sheila A. Lukehart. Biological Basis for Syphilis. Clin. Microbiol. Rev. 2006; 19(1):29-49
Natural course of untreated syphilis – showing time frames and the approximate proportion of persons developing different forms of clinical disease (in parentheses). It is not known what proportion of initially infected persons develop primary or secondary manifestations.
Sutton, M, Dorell, C, Glob. libr. women's med., 2009.
The common manifestations of secondary syphilis are: (i) a generalised skin rash (75–100%) (ii) lymphadenopathy (50–80%) and (iii) mucocutaneous lesions like mucous patches and condyloma lata (40–50%).
Generalised rash, year 1948 (left). Rash involving the palms (and soles) (center). Peri-anal condylomata, year 1944 (right).
Latent syphilis is the stage of disease during which there are no clinical signs but specific treponemal antibody test are positive.
Tertiary or late syphilis is a slowly progressive inflammatory disease that can affect any organ and have protean manifestations 3 to 30+ years after the initial infection. It can be divided into late "benign" syphilis (gummata), cardiovascular syphilis and neurosyphilis. Syphilitic osteitis is also a feature of late disease.
The gumma is an indolent non-specific granulomatous lesion most commonly occurring in bones and joints, skin and and subcutaneous tissues, but they can occur in any organ. They can vary from microscopic to large masses, from superficial nodules to deep ulcerating lesions, with the general result of local destruction. Involution is followed by scarring.
Gumma of the sternum in a 57 year old man, year 1946 (top left). Gumma of the neck in a 46 year old woman, year 1930 (bottom left). Multiple gummata of head and shoulder, probable chronic osteitis of left ulna, year unknown (right). Syphilitic gumma showing central coagulated necrotic material with margins of palisading macrophages and fibroblasts, surrounded by large numbers of mononuclear white cells. Treponemes are scanty in gummas and difficult to demonstrate.
Image credit: Yale Rosen https://www.flickr.com/photos/pulmonary_pathology/9727667274/
Glossitis can be a feature of tertiary syphilis and it predisposes to carcinoma, especially in smokers.
Condylomata at the angles of the mouth and chronic glossitis in a 52 year old man, year 1944 (left).Illustration (right)
Image credit: Morris M. A case of late syphilitic glossitis treated by Salversan (Erlich-Hata). Br Med J. Mar 30, 1912; 1(2674): 712–712.1.
SYPHILITIC AORTITIS: The ascending aorta and aortic arch are most often affected. A syphilitic endarteritisinvolving the vasa vasorum in the adventitia results in ischaemic destruction of elastic and muscle fibres within the media. Reparative scarring and vascularisation weaken the wall, leading to dilatation (either diffuse or aneurysmal). The intima undergoes compensatory thickening, on top of which atheroma is then frequently superimposed. Secondary effects of syphilitic aortitis include:
(i) dilatation of the aortic valve ring leading to aortic incompetence, which in turn leads to dilatation and hypertrophy of the left ventricle.
(ii) involvement of the ostia of the coronary arteries, producing cardiac ischaemia.
SYPHILITIC AORTIC VALVULITIS: This is an extension of syphilitic aortitis to the valve cusps, and is thus confined to the aortic valve. There is often a tendency for the free edge of the cusp to be most affected.
Acute syphilitic meningitis is not uncommon during the secondary stage of syphilis. If untreated, up to 10% of patient progress to late neurosyphilis:
- Meningovascular syphilis presents with stroke, usually within 5 years of infection
- General paresis (cortical) and tabes dorsalis (spinal cord) are the main forms of parenchymatous neurosyphilis, presenting 10-20 and 15-20 years after infection, respectively. General paresis is a dementia due to diffuse parenchymal atrophy resulting from chronic meningoencephalitis. Tabes dorsalis is a myelopathy due to chronic inflammatory disease of the dorsal roots and ganglia with associated degeneration of the posterior columns.
- The eyes and ears can be affected by neurosyphilis through optic neuritis/atrophy and VIIIth nerve involvement.
In tabes dorsalis the dorsal aspect of the cord becomes flattened and myelin stains show a distinct area of demyelination as seen in this section of lumbar spinal cord (arrows indicate dorsal roots).
Image credit: http://www.urmc.rochester.edu/libraries/courses/neuroslides/lab3b/slide120.cfm Charcot's joints (secondary to tabes dorsalis), a destructive neuropathic arthropathy resulting from the loss of pain sensation and proprioception, year 1942.