Tertiary syphilis is the third period of syphilis that develops in insufficiently treated patients or patients who have not been treated at all. It is manifested by the formation of syphilitic infiltrates (granulomas) in the skin, mucous membranes, bones and internal organs. Granulomas compress and destroy the tissues in which they are located, which can lead to a fatal outcome of the disease. Diagnosis includes clinical examination of the patient, serological and immunological reactions, examination of affected systems and organs. Therapy is carried out by courses of penicillin-bismuth treatment with the additional use of symptomatic and general tonic agents.
Currently, disease is a rare form of syphilis, since in modern venereology, the detection and treatment of most cases of the disease occurs at the stage of primary or secondary syphilis. Disease can occur in patients who have undergone an incomplete course of treatment or who have received drugs in insufficient dosage. In the absence of treatment for syphilis (for example, due to undiagnosed latent syphilis), about a third of patients develop tertiary syphilis. The factors predisposing to the occurrence of tertiary syphilis are concomitant chronic intoxication and diseases, alcoholism, senile and childhood age.
A patient is practically not contagious, since the few treponemes in his body are located deep inside the granulomas and die when they disintegrate.
Symptoms of tertiary syphilis
Earlier in the literature it was indicated that tertiary syphilis develops 4-5 years after infection with pale treponemas. However, recent data indicate that this period has increased to 8-10 years. Tertiary syphilis is characterized by a long course with long latent periods, sometimes taking several years.
Skin lesions in tertiary syphilis — tertiary syphilis — develop over months and even years without signs of inflammation and any subjective sensations. Unlike the elements of secondary syphilis, they are located on a limited area of the skin and slowly regress, leaving behind scars. Manifestations of tertiary syphilis include tubercle and gum syphilis.
Disease is an infiltrative nodule formed in the dermis, slightly protruding above the surface of the skin, having a size of 5-7 mm, red-brown color and dense consistency. Usually, with tertiary syphilis, nodular eruptions occur in waves and asymmetrically on a local area of the skin, while individual elements are at different stages of their development and do not merge with each other. Over time, tubercular syphilis undergoes necrosis with the formation of a rounded ulcer with smooth edges, an infiltrated base and a smooth clean bottom. The healing of the ulcer of tertiary syphilis takes weeks and months, after which an area of atrophy or a scar with hyperpigmentation along the edge remains on the skin. The scars that appear as a result of the resolution of several grouped tubercle syphilis form a picture of a single mosaic scar. Repeated eruptions of tertiary syphilis never occur in the area of scars.
Gummous syphilis (syphilitic gumma) is more often a single one, the formation of several gummas in one patient is less common. Gumma is a painless node located in the subcutaneous tissue. The most frequent localization of gum is the forehead, the anterior surface of the shins and forearms, the area of the knee and elbow joints. At first, the node is movable and not soldered to adjacent tissues. Gradually, it increases in size and loses mobility due to fusion with the surrounding tissues. Then a hole appears in the middle of the node, through which the gelatinous liquid is separated. The slow enlargement of the hole leads to the formation of ulcers with crater-like breaking edges. At the bottom of the ulcer, a necrotic rod is visible, after which the ulcer heals with the formation of a stellate retracted scar. Sometimes with tertiary syphilis, gumma is resolved without turning into an ulcer. In such cases, there is a decrease in the node and its replacement with dense connective tissue.
In tertiary syphilis, gum ulcers can capture not only the skin and subcutaneous tissue, but also the underlying cartilage, bone, vascular, and muscle tissues, which leads to their destruction. Gum syphilis can be located on the mucous membranes. Most often it is the mucous membrane of the nose, tongue, soft palate and pharynx. Defeat by tertiary syphilis of the nasal mucosa leads to the development of rhinitis with purulent discharge and violation of nasal breathing, then the destruction of nasal cartilage occurs with the formation of a characteristic saddle deformity, nasal bleeding is possible. With the defeat of tertiary syphilis of the mucous membrane of the tongue, glossitis develops with difficulty in speech and chewing food. Lesions of the soft palate and pharynx lead to nasal voice and ingestion of food when chewing into the nose.
Disorders 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. Lesions of the bone system in tertiary syphilis can manifest as osteoporosis or osteomyelitis, liver damage — chronic hepatitis, stomach — gastritis or stomach ulcer. In rare cases, lesions of the kidneys, intestines, lungs, and nervous system (neurosyphilis) are noted.
The main and most serious complications are associated with damage to the cardiovascular system. So, syphilitic aortitis can lead to an aortic aneurysm, which can gradually squeeze the surrounding organs or suddenly rupture with the development of massive bleeding. Syphilitic myocarditis can be complicated by heart failure, spasm of coronary vessels with the development of myocardial infarction. Against the background of complications of tertiary syphilis, the death of the patient is possible, which is observed in about 25% of cases of the disease.
In tertiary syphilis, 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 FTA and TPI, which are positive in most cases of tertiary syphilis (92-100%), are of primary importance.
To identify the degree of damage to somatic systems and organs, according to indications, ECG, ultrasound of the heart, aortography, bone radiography, rhinoscopy and pharyngoscopy, gastroscopy and ultrasound of the liver, examination of liver samples, lung radiography, lumbar puncture with examination of cerebrospinal fluid, etc. are performed. The patient may need additional consultation with a cardiologist, neurologist, otolaryngologist, gastroenterologist, oculist.
Differential diagnosis is carried out with scrofuloderma, indurative erythema, ulcerative manifestations of skin cancer, miliary tuberculosis, actinomycosis, leprosy, decaying 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 proceed to penicillin therapy in two courses with an interval of 2 weeks. The duration of courses and dosages are selected in accordance with the selected drug, the patient’s condition and the localization of gum. Penicillin therapy is supplemented with the introduction of bismuth preparations. If there are contraindications to bismuth (kidney or liver damage), the third course of penicillin therapy is additionally prescribed. During the treatment of tertiary syphilis, it is mandatory to monitor the main indicators of the functioning of the affected organs: clinical blood and urine analysis, biochemical liver tests, coagulogram, ECG, etc. According to the indications, general tonic agents and symptomatic treatment are prescribed.