Syphilis – Clinical Aspects of Late Syphilis Thad Zajdowicz, MD, MPH Thad Zajdowicz, MD, MPH Medical Director, STD/HIV Program Chicago Dept of Public Health

Why a lecture on syphilis? Although syphilis is an eminently treatable disease, 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 for centuries. Further, control of syphilis is vital because of its interactions with HIV. This lecture will focus on clinical manifestations of late syphilis.

Objectives To review the clinical manifestations of late syphilis

Clinical 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 Untreated Syphilis

Syphlitic Aortic Aneurysm

Aortic Aneurysm

Syphilitic Aortitis Tree-barking

Ruptured Aortic Aneurysm Tree-barking Clot

Stenosis of Coronary Arteries

Neurosyphilis Asymptomatic –no clinical manifestations –defined by presence of CNS abnormalities including: WBC > 5/mm 3, mostly lymphocytes elevated protein reactive CSF-VDRL (variable) –may progress to overt neurosyphilis

Neurosyphilis 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 neurosyphilis 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 neurosyphilis 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 Joint

Gumma of Face

Gummas of the Nose

Gumma - Nose

Gummas - Scalp

Gmmas of Arm u

Gummas - Arm

Ulcerating Gumma

Conclusions 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 Information The following sites are useful if more information on syphilis is sought: for Disease Control Health Organization Social Hygiene Assoc Naval Hospital