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

3. 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.

4. Objectives To review the clinical manifestations of late syphilis

5. 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

6. Natural History of Untreated Syphilis

7. Syphlitic Aortic Aneurysm

8. Aortic Aneurysm

9. Syphilitic Aortitis Tree-barking

10. Ruptured Aortic Aneurysm Tree-barking Clot

11. Stenosis of Coronary Arteries

12. 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

13. 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

14. 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

15. 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

16. Charcot Joint

17. Gumma of Face

18. Gummas of the Nose

19. Gumma - Nose

20. Gummas - Scalp

21. Gmmas of Arm u

22. Gummas - Arm

23. Ulcerating Gumma

24. 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

25. Sources of Information The following sites are useful if more information on syphilis is sought: www.cdc.govwww.cdc.govCenters for Disease Control www.who.intwww.who.intWorld Health Organization www.ashastd.orgwww.ashastd.orgAmerican Social Hygiene Assoc www.vnh.orgwww.vnh.orgVirtual Naval Hospital