Tertiary syphilis – clinical picture, differential diagnosis, treatment.
If a person with secondary syphilis does not undergo treatment and the rash goes away, the infected person will progress to the latent (hidden) stage of syphilis, thus they will not have any symptoms for a long period of time (latent period). This period may range from 1 to 20 years. during this stage an accurate diagnosis can only be made through blood testing, the person's history, or the birth of a child with congenital syphilis. A person is contagious during the early part of the latent stage and may be contagious during the latent period when no symptoms are present.
If untreated, the tertiary stage may begin as early as 1 year after infection or at any time during a person's lifetime. This is the most destructive stage of syphilis.
- Clinical features: It can divided into 3 main forms:
- Late Benign syphilis – This form is characterized by gumma and appears 3-10 years after infection. It is defined as a highly destructive lesion that usually occurs in skin and bones but can also appear in other tissues. It’s a slowly progressive, painless, dull red nodule or plaque. On the skin, 2 forms of lesions may appear:
- A) Nodular & Noduloulcerative lesion – deep indurated multiple nodules that are reddish – brown in color. They vary in size. They are distributed in an arciform pattern. Found on the face, scapular and inter-scapular areas and extremities. They may heal without breaking but they do scar. If nodular lesions break down into Noduloulcerative form they heal leaving atrophic non-contractile scar.
- B) Solitary Gumma – Subcutaneous process that involves the skin secondarily. Found on the thighs, buttocks, shoulders, forehead and scalp. As it becomes necrotic it has the characteristics of “cold abscess”. These lesions resolve promptly with effective treatment.
- Cardiovascular syphilis – affects the heart and the blood vessels. 10% of untreated syphilis develop into Cardiovascular syphilis 10-40 years after the intial infection. It occurs due to localized infection (gumma) or generalized infection that leads to heart failure. It can cause aortic regurge, aneurysm or coronary osteal stenosis.
- Neurosyphilis – may be asymptomatic or symptomatic. In asymptomatic neurosyphilis, there are no symptoms of CNS involvement but the CSF is abnormal (with elevated lymphocytes and proteins, positive VDRL tests). 20% of these cases progress into symptomatic neurosyphilis. In symptomatic neurosyphilis, invasion of the CNS occur early when generalized dissemination occurs.
- Differential diagnosis:
- Granuloma annulare