Tertiary syphilis is the third period of syphilis, developing in insufficiently treated patients or patients who have not undergone treatment at all. Manifested by the formation of syphilitic infiltrates (granulomas) in the skin, mucous membranes, bones and internal organs.
Granulomas with tertiary syphilis squeeze and destroy the tissue in which they are located, which can lead to death of the disease.
Diagnosis of tertiary syphilis includes a clinical examination of the patient, setting of serological and immunological reactions, examination of the affected systems and organs. Therapy of tertiary syphilis is carried out by courses of penicillin-bismuth treatment with the additional use of symptomatic and tonic means.
Tertiary syphilis explained: what is it, manifestation and risks
Currently, tertiary syphilis is a rare form of syphilis, since in modern venereology, the identification and treatment of most cases of the disease occurs at the stage of primary or secondary syphilis. Tertiary syphilis can occur in patients who have undergone incomplete treatment or have received drugs in insufficient dosage. In the absence of treatment for syphilis (for example, in connection with undiagnosed latent syphilis), about one third of the patients develop tertiary syphilis.
Predisposing factors for the emergence of tertiary syphilis are concomitant chronic intoxications and diseases, alcoholism, senile and children age.
A patient with tertiary syphilis is practically not contagious, since the few treponemas in his body are located deep inside the granulomas and die during their disintegration.
Symptoms of tertiary syphilis
Earlier in the literature indicated that tertiary syphilis develops after 4-5 years from the moment of infection with pale treponema. However, recent data suggest that this period increased to 8-10 years. Tertiary syphilis is characterized by a long course with large latent periods, sometimes taking several years.
Tertiary syphilis skin lesions – tertiary syphilides – develop over months and even years without signs of inflammation and any subjective sensations. Unlike elements of secondary syphilis, they are located on a limited area of the skin and slowly regress, leaving behind scars. The manifestations of tertiary syphilis are lumpy and gummous syphilide.
Lumpy syphilide – an infiltrative nodule formed in the dermis, slightly protruding above the skin surface, having a size of 5-7 mm, reddish brown color and dense consistency. Usually, in case of tertiary syphilis, nodular eruptions occur in a wavy and asymmetrical manner in a local area of the skin, while individual elements are in different stages of their development and do not merge with each other. Over time, lumpy syphilide undergoes necrosis with the formation of a rounded ulcer with smooth edges, infiltrated base and a smooth clean bottom.
The healing of the ulcer of tertiary syphilis lasts for weeks and months, after which an atrophy site or scar with hyperpigmentation along the edge remains on the skin. Scars that appear as a result of the resolution of several grouped tubercular syphilides form a picture of a single mosaic scar. Repeated rash of tertiary syphilis never occurs in the area of scars.
Gummous syphilide (syphilitic gum) is more likely to be isolated, less often the formation of several gums in one patient. Gumma is a painless node located in the subcutaneous tissue. The most frequent localization of gummas of tertiary syphilis is the forehead, the anterior surface of the legs and forearms, the area of the knee and elbow joints. Initially, the node is mobile and not soldered to the adjacent tissues.
Gradually, it increases in size and loses mobility due to adhesion with the surrounding tissues. Then, in the middle of the node, a hole appears through which the gelatinous liquid is separated.
Slow enlargement of the aperture leads to the formation of an ulcer with crater-like breaking edges. At the bottom of the ulcer a necrotic rod is seen, after the discharge of which the ulcer heals with the formation of a star-shaped retracted scar. Sometimes with tertiary syphilis, gum is resolved without going into an ulcer. In such cases, there is a decrease in the node and its replacement by dense connective tissue.
In the case of tertiary syphilis, gummous ulcers can capture not only the skin and subcutaneous tissue, but also the underlying cartilage, bone, vascular, muscle tissue, which leads to their destruction. Gummous syphilides can be located on the mucous membranes.
Most often it is the mucous membrane of the nose, tongue, soft palate and pharynx. Tertiary syphilis lesion of the nasal mucosa leads to the development of rhinitis with purulent discharge and a violation of nasal breathing, then the destruction of the nasal cartilage occurs with the formation of a characteristic saddle-shaped deformity, nasal bleeding is possible.
With the defeat of tertiary syphilis of the mucous membrane of the tongue develops glossitis with difficulty speaking and chewing food. Lesions of the soft palate and pharynx lead to nasal voices and food ingestion when chewing on the nose.
Violations on the part of somatic organs and systems caused by tertiary syphilis are observed on average 10–12 years after infection.
In 90% of cases, tertiary syphilis occurs with damage to the cardiovascular system in the form of myocarditis or aortitis. The lesions of the skeletal system in tertiary syphilis can be manifested by osteoporosis or osteomyelitis, liver damage – chronic hepatitis, stomach – gastritis or gastric ulcer.
In rare cases, there are lesions of the kidneys, intestines, lungs, nervous system (neurosyphilis).
Complications of tertiary syphilis
The main and most terrible complications of tertiary syphilis are associated with damage to the cardiovascular system. Thus, syphilitic aortitis can lead to an aortic aneurysm, which can gradually squeeze the surrounding organs or suddenly burst with the development of massive bleeding.
Syphilitic myocarditis may be complicated by heart failure, spasm of the coronary vessels with the development of myocardial infarction.
Against the background of complications of tertiary syphilis, the patient may die, which is observed in about 25% of cases.
Diagnosis of tertiary syphilis
In tertiary syphilis, the diagnosis is based primarily on clinical and laboratory data. In 25-35% of patients with tertiary syphilis, the RPR test gives a negative result; therefore, blood tests using RIF and RIBT, which are positive in most cases of tertiary syphilis (92-100%), are of primary importance.
To determine the extent of damage of somatic systems and organs, according to indications, ECG, heart ultrasound, aortography, x-rays of bones, rhinoscopy and pharyngoscopy, gastroscopy and ultrasound of the liver, liver test, lung x-ray, lumbar puncture with cerebrospinal fluid, etc. may be required.
The patient may need additional consultation of a cardiologist, neurologist, otolaryngologist, gastroenterologist, oculist.
Differential diagnosis of tertiary syphilis is carried out with scrofuloderma, indurative erythema, ulcerative manifestations of skin cancer, miliary tuberculosis, actinomycosis, leprosis, disintegrating lipomas.
Treatment of tertiary syphilis
Therapy of tertiary syphilis begins with a preparatory stage in the form of a 2-week course of erythromycin or tetracycline. Then they break into penicillin therapy with two courses with an interval of 2 weeks. Duration of courses and dosages are selected in accordance with the selected drug, the patient’s condition and localization of gum. Penicillin therapy supplement the introduction of bismuth preparations.
When there are contraindications to bismuth (kidney or liver damage), an additional third course of penicillin therapy is prescribed. During the treatment of tertiary syphilis, monitoring of the main indicators of the functioning of the affected organs is always carried out: clinical analysis of blood and urine, liver biochemical tests, coagulogram, ECG, etc.
According to the indications, general-strengthening remedies and symptomatic treatment are prescribed.