Tertiary syphilis: symptoms

Tertiary syphilis develops in patients who have received inferior treatment, or in the absence of it in the previous stages of syphilis. This stage appears on the 3-4th year of the disease and continues indefinitely. Unlike the secondary period in the tertiary, the internal organs, central nervous system and musculoskeletal system are involved in the process much more often. Syphilis of the Tertiary period is characterized by a long existence (months and years), they show a very small number of pale treponemes (in this connection, studies for the presence of pathogens are not carried out at all), low contagion, a tendency to develop specific lesions in places of nonspecific stimuli , in places of mechanical injuries). Classical serological reactions in 1/3 of patients with tertiary syphilis are negative. In this period, the intensity of specific immunity is gradually reduced (this is due to a decrease in the number of pale treponemes in the body of the patient), in connection with which it becomes possible genuine insuperinfection with the development of a solid chancre at the site of a new introduction of pale treponemes.

Syphilis of the Tertiary period is represented by tubercular and gummy elements.

The main element of the tubercular syphillis is a small, dense tubercle of a hemispherical shape, the size of a cherry stone, with a smooth or shiny surface, a dark red or a cyanotic red color. The tubercle quickly, within a week or month, softens and ulcerates with the formation of a round, rather deep ulcer with cylindrical, steeply cut edges. Gradually, the bottom of the ulcer clears from decay, is covered with granulations and turns into a pigmented periphery atrophic scar, which never gives rise to new rashes. The group of scars has a mosaic appearance.

Gumma occurs in the subcutaneous tissue and is a boundedly mobile ball the size of a walnut, a cyanotic red color, a dense elastic consistency, with sharp boundaries. Subjective sensations are absent or insignificant. Over time, the softening and decomposition of gumma are noted with the formation of a necrotic stem ("gummy rod"). As a result, there is a deep ulcer, the bottom of which is covered with the remnants of a decaying infiltrate. The ulcer has rounded outlines, a deep bottom and very characteristic cylindrical, thick, dense elastic cyanotic-red edges. Then the ulcer cicatrizes, leaving a discolored stellate scar with a zone of hyperpigmentation around the periphery. Gunma often located on the mucous membranes of the nasal cavity, throat. With the location of the gum in the tongue, hard and soft palate, nose, throat, larynx, severe and often unremovable consequences (speech, swallowing, breathing, "saddle" nose, complete destruction of the nose, perforation of the hard palate) are noted. Often there is a single gum, rarely there are multiple gums.

Tertiary syphilis

Tertiary syphilis is characterized by the appearance of gum or lesion of the cardiovascular system, but not signs of non-irosifilis. Patients who are not allergic to penicillin and symptoms of non-irosifilis should be treated according to the following scheme.

Recommended scheme

Benzathine penicillin G, total 7.2 million units, 3 doses of 2.4 million units IM / m at intervals of 1 week.

Other observations on patient management

Before treatment in patients with symptoms of late syphilis, CSF should be examined. Some experts recommend treating all patients with cardiovascular syphilis according to the scheme of treatment of non-irosifilis. A full review of the management of patients with cardiovascular or gummy syphilis is beyond the scope of this manual. The management of such patients should be accompanied by expert advice.

Follow-up

There is very little data on long-term follow-up of patients with late syphilis. The response to treatment depends, in particular, on the nature of the lesions.

Special Remarks

Allergy to penicillin

Patients with penicillin allergy should be treated according to the schemes recommended for the treatment of late latent syphilis.

Pregnancy

Pregnant women with penicillin allergy should be treated with penicillin, after desensitization, if necessary (see Management of patients with penicillin allergy and Syphilis during pregnancy).

Neurosyphilis

Treatment

The defeat of the central nervous system can be observed at any stage of syphilis. If patients with syphilis have clinical signs of nervous system damage (for example, symptoms from the organs of vision and hearing, paresis of the cranial nerves, signs of meningitis), it is necessary to examine CSF.

Syphilitic uveitis or other eye injuries are often associated with neurosyphilis, such patients should be treated according to the recommendations for the treatment of neurosyphilis. CSF should be performed in all such patients. In case of detection of abnormalities in CSF, it is necessary to re-examine it during follow-up to monitor the effectiveness of the treatment.

Patients with neurosyphilis or syphilitic eye disease (eg, uveitis, neuroretinitis or optic neuritis) without any allergy to penicillin should be treated according to the following scheme.

Recommended scheme

The water-soluble crystalline penicillin G is 18-24 million units daily, 2-4 million units every 4 hours for 10-14 days.

Patients can be treated according to the following alternative scheme when it is tolerated.

Alternative scheme

Procaine penicillin 2.4 million units IM in / m daily plus probenecid 500 mg orally 4 times a day, both drugs for 10-14 days.

The duration of this scheme is shorter than that for the treatment of late syphilis in the absence of non-pyrosis. Therefore, after the completion of this course of treatment for non-irosifilis, some experts propose the use of 2,4 million benzathine penicillin in / m to provide a comparable total duration of treatment.

Other observations on patient management

Other observations on managing patients with neurosyphilis are as follows:

• All patients with syphilis should be tested for HIV.
• Many experts recommend treating patients with auditory disorders caused by syphilis, as well as neurosyphilis, regardless of the results of the CSF study. Although systemic steroids are often used as an adjunctive therapy for syphilitic ear lesions, the advantages of this method have not been proven.

Follow-up

If a pleocytosis is detected in the first study in the CSF, it should be re-examined in these patients every 6 months until the number of cells returns to normal. Follow-up can also be used to determine changes in VDRL results from CSF and the amount of protein in the CSF to assess the effectiveness of treatment, although the change in these two parameters is slower and the detection of abnormalities is less important. If the number of cells in CSF does not decrease within 6 months or if CSF parameters are not completely normalized after 2 years, it is necessary to consider the question of re-treatment.

Special Remarks

Allergy to penicillin

Systematic data on the evaluation of the effectiveness of alternative regimens for the treatment of non-pyrolysis are not available. Therefore, patients with penicillin allergy should be treated with penicillin, if necessary, after desensitization or advised by an expert. In some situations, it may be useful to conduct skin tests to confirm allergies to penicillin (see Management of patients with penicillin allergy).

Pregnancy

Pregnant patients with penicillin allergy should be desensitized, if necessary, and then treated with penicillin (see Management of patients with penicillin allergy and Syphilis during pregnancy).