STD

Tertiary Syphilis

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Tertiary Syphilis, Syphylitic Gumma, Gummatous Syphilis, Gumma

  • See Also
  1. Syphilis
  2. Sexually Transmitted Disease
  3. Primary Syphilis
  4. Secondary Syphilis
  5. Latent Syphilis
  6. Tertiary Syphilis
  7. Syphilitic Gumma
  8. Cardiovascular Syphilis
  9. Neurosyphilis
  10. Syphilis Testing
  11. Genital Ulcer
  • Epidemiology
  1. Untreated Latent Syphilis progresses to Tertiary Syphilis in one third of patients
  2. Occurs years to decades afer initial untreated Syphilis infection
  • Pathophysiology
  1. Low-level Syphilis infection with strong immune response
  2. Immune-mediated inflammatory changes result in injury to organs, small vessels and nerves
  • Types
  1. Late benign Syphilis (or Gummatous Syphilis, 50% of Tertiary Syphilis cases)
    1. Presents with gumma and Granulomas
      1. Destructive Granulomatous lesions (fungating masses) may affect any area
      2. Skin lesions may appear as well-demarcated psoriatic-like Plaques
      3. Bone involvement may result in deep, bone pain
    2. May form 1 to 10 years after initial infection (up to 40 years later)
    3. Responds rapidly to treatment
  2. Cardiovascular Syphilis (10% of untreated patients)
    1. Onset >10 years after Primary Syphilis
    2. Starts with chronic inflammation of the vasa vosorum (small arteriole tributaries to the aorta)
      1. Inflammation ultimately spreads to the aorta, with destruction, weakening of its media
      2. Results in irreversible large vessel complications
    3. Typically involves Great Vessels (especially ascending aortitis)
    4. Thoracic Aortic Aneurysm (including ascending aortic aneurysm)
      1. Results in Aortic Dissection
      2. Proximal involvement may result in aortic valve insufficiency or Coronary Artery Disease
  3. Neurosyphilis (Occurs in 8-10% of untreated Syphilis)
    1. Treponemal penetration of the blood brain barrier
    2. Asymptomatic Neurosyphilis may occur without clinical findings (but CSF Syphilis positive)
    3. Manifestations
      1. See Neurosyphilis
      2. Tabes Dorsalis (Peripheral Neuropathy, including Argyll-Robertson Pupil)
      3. Intracranial gummata (appear as CNS Mass)
      4. Syphilitic Paresis
      5. Subacute Meningitis
      6. Meningovascular Syphilis
      7. Dementia Paralytica
  • Labs
  1. See Syphilis Testing
  • Management
  1. See Syphilis
  2. See Neurosyphilis
  • Complications
  1. Thoracic Aortic Aneurysm (from ascending aortitis)
  2. Neurosyphilis complications
  • References
  1. Kirk, McHugh and Parnell (2023) Crit Dec Emerg Med 37(8): 23-9
  2. Mattel (2012) Am Fam Physician 86(5): 433-40 [PubMed]
  3. Ricco (2020) Am Fam Physician 102(2): 91-8 [PubMed]