Syphilis – Clinical Syphilis – Clinical Aspects Aspects

of Late Syphilisof Late Syphilis

Thad Zajdowicz, MD, MPHMedical Director, STD/HIV ProgramMedical Director, STD/HIV Program

Chicago Dept of Public HealthChicago Dept of Public Health

Why a lecture on syphilis?Why a lecture on syphilis?

Although syphilis is an eminently treatabledisease, its continuing occurrence illustrates that our control efforts still need to be improved. The disease remains elusive clinically even today, and unless thought of and sought for can silently cause disease as it has forcenturies. Further, control of syphilis is vital because of its interactions with HIV. This lecture will focus on clinical manifestations of late syphilis.

ObjectivesObjectives

•To review the clinical manifestations of late syphilis

Clinical StagesClinical Stages

• Syphilis is conventionally divided into several stages:– Primary– Secondary– Latent– Late, or tertiary

• This lecture will focus on late syphilis – cardiovascular, neurosyphilis, and gummas

Natural History of Natural History of Untreated SyphilisUntreated Syphilis

Syphlitic Aortic Syphlitic Aortic AneurysmAneurysm

Aortic AneurysmAortic Aneurysm

Syphilitic AortitisSyphilitic Aortitis

Tree-barkingTree-barking

Ruptured Aortic Ruptured Aortic AneurysmAneurysm

Tree-barkingTree-barking ClotClot

Stenosis of Coronary Stenosis of Coronary ArteriesArteries

NeurosyphilisNeurosyphilis

• Asymptomatic– no clinical manifestations– defined by presence of CNS

abnormalities including:•WBC > 5/mm3, mostly lymphocytes•elevated protein•reactive CSF-VDRL (variable)

– may progress to overt neurosyphilis

NeurosyphilisNeurosyphilis

• Meningeal neurosyphilis– includes acute syphilitic meningitis– headache, fever, CSF abnormalities

• Meningovascular neurosyphilis– “syphilitic stroke”– hemiparesis, hemiplegia, aphasia,

seizure• Parenchymatous neurosyphilis

– general paresis– tabes dorsalis

Parenchymatous Parenchymatous neurosyphilisneurosyphilis

•General paresis (dementia paralytica)– T. pallidum directly invades cerebrum

•memory loss, personality changes, headache, delusions, seizure

– neurologic findings include: •Argyll Robertson pupils•slurred speech•expressionless face•tremors

Parenchymatous Parenchymatous neurosyphilisneurosyphilis

•Tabes dorsalis– occurs after long latent period

(20-25 yrs.)•early features: lightning pains, paresthesias, diminished DTRs, poor pupillary responses

•late features: ataxia, bladder and rectal disturbances, Charcot joints, “visceral crises”

– cranial nerve involvement often overlooked– “tabetic facies” due to ptosis and flabbiness

of facial muscles

Charcot JointCharcot Joint

Gumma of FaceGumma of Face

Gummas of the NoseGummas of the Nose

Gumma - NoseGumma - Nose

Gummas - ScalpGummas - Scalp

Gmmas of ArmGmmas of Arm

Gummas - ArmGummas - Arm

Ulcerating GummaUlcerating Gumma

ConclusionsConclusions

• Late complications of syphilis occurred in about 1/3 of patients in the preantibiotic era

• Prompt penicillin therapy of early disease not only prevents infection in others, but also prevents late complications

• Neurosyphilis may present and progress rapidly in patients co-infected with HIV

Sources of InformationSources of Information

The following sites are useful if more information on syphilis is sought:

www.cdc.gov Centers for Disease Controlwww.who.int World Health Organizationwww.ashastd.org American Social Hygiene Assocwww.vnh.org Virtual Naval Hospital