infectious diseases
Syphilis
Symptoms and Signs of Syphilis
Syphilis may manifest at any stage and may affect multiple or single organs, mimicking many other disorders. Syphilis may be accelerated by coexisting HIV infection; in these cases, eye involvement, meningitis, and other neurologic complications are more common and more severe. Syphilis should be suspected in patients with typical mucocutaneous lesions or unexplained neurologic disorders, particularly in areas where the infection is prevalent. In such areas, it should also be considered in patients with a broad range of unexplained findings. Because clinical manifestations are so diverse and advanced stages are now relatively rare in most developed countries, syphilis may escape recognition. Syphilitic chancres may appear on or around the genitals. Image courtesy of Drs. Gavin Hart and N. J. Flumara via the Public Health Image Library of the Centers for Disease Control and Prevention. Syphilitic chancres may appear on or around the anus. Image courtesy of Dr. Susan Lindsley via the Public Health Image Library of the Centers for Disease Control and Prevention. Syphilitic chancres may appear on or around the mouth. Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention. Syphilitic chancres may appear on or around the digits or ostomy sites. Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention. After an incubation period of 3 to 4 weeks (range 1 to 13 weeks), a primary lesion (chancre) develops at the site of inoculation. The initial red papule quickly forms a chancre, usually a painless ulcer with a firm base; when rubbed, it produces clear fluid containing numerous spirochetes. Nearby lymph nodes may be enlarged, firm, and nontender. Chancres can occur anywhere but are most common on the following: Penis, anus, and rectum in men Vulva, cervix, rectum, and perineum in women Lips or mouth About half of infected women and one third of infected men are unaware of the chancre because it causes few symptoms. Chancres in the rectum or mouth, usually occurring in men, are often unnoticed. The chancre usually heals in 3 to 12 weeks. Then, people appear to be completely healthy. The spirochete spreads in the bloodstream, producing widespread mucocutaneous lesions, lymph node swelling, and, less commonly, symptoms in other organs. Symptoms typically begin 6 to 12 weeks after the chancre appears; about 25% of patients still have a chancre. Fever, loss of appetite, nausea, and fatigue are common. Headache (due to meningitis), hearing loss (due to otitis), balance problems (due to labyrinthitis), visual disturbances (due to retinitis or uveitis), and bone pain (due to periostitis) can also occur. Over 80% of patients have mucocutaneous lesions; a wide variety of rashes and lesions occur, and any body surface can be affected. Without treatment, lesions may disappear in a few days to weeks, persist for months, or return after healing, but all eventually heal, usually without scarring. Syphilitic dermatitisis usually symmetric and more marked on the palms and soles. The individual lesions are round, often scale, and may coalesce to produce larger lesions, but they generally do not itch or hurt. After lesions resolve, the affected areas may be lighter or darker than normal. If the scalp is involved, alopecia areata often occurs. Condyloma lataare hypertrophic, flattened, dull pink or gray papules at mucocutaneous junctions and in moist areas of the skin (eg, in the perianal area, under the breasts); lesions are extremely infectious. Lesions of the mouth, throat, larynx, penis, vulva, or rectum are usually circular, raised, and often gray to white with a red border. Secondary syphilis can affect many other organs: About half of patients have lymphadenopathy, usually generalized, with nontender, firm, discrete nodes, and often hepatosplenomegaly. About 10% of patients have lesions in other organs, such as the eyes (uveitis), bones (periostitis), joints, meninges, kidneys (glomerulitis), liver (hepatitis), or spleen. About 10 to 30% of patients have mild meningitis, but < 1% have meningeal symptoms, which can include headache, neck stiffness, cranial nerve lesions, deafness, and eye inflammation (eg, optic neuritis, retinitis). However, acute or subacute meningitis is more common among patients with HIV infection and may manifest as meningeal symptoms or strokes due to intracranial vasculitis. Secondary syphilis mimics many other dermatoses, causing a diffuse rash that may be macular, papular, or pustular, with discrete or confluent lesions. Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention. Secondary syphilis mimics many other dermatoses, causing a diffuse rash that may be macular, papular, or pustular, with discrete or confluent lesions. Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention. A maculopapular rash on the palms or soles is characteristic of secondary syphilis. Image courtesy of the Public Health Image Library of the Centers for Disease Control and Prevention. A maculopapular rash on the palms or soles is characteristic of secondary syphilis. Image courtesy of Susan Lindsley via the Public Health Image Library of the Centers for Disease Control and Prevention. Latent syphilis can be early (< 1 year after infection) or late (≥ 1 year after infection). Symptoms and signs are absent, but antibodies, detected by serologic tests for syphilis (STS), persist. Because symptoms of primary and secondary syphilis are often minimal or ignored, patients frequently are first diagnosed during the latent stage when routine blood tests for syphilis are done. Syphilis may remain latent permanently, but relapses with contagious skin or mucosal lesions may occur during the early latent period. Patients are often given antibiotics for other disorders, which may cure latent syphilis and may account for the rarity of late-stage disease in developed countries. About one third of untreated people develop late syphilis, although not until years to decades after the initial infection. Lesions may be clinically classified as Benign tertiary syphilis Cardiovascular syphilis Neurosyphilis Benign tertiary gummatous syphilisusually develops within 3 to 10 years of infection and may involve the skin, bones, and internal organs. Gummas are soft, destructive, inflammatory masses that are typically localized but may diffusely infiltrate an organ or tissue; they grow and heal slowly and leave scars. Benign tertiary syphilis of boneresults in either inflammation or destructive lesions that cause a deep, boring pain, characteristically worse at night. Cardiovascular syphilisusually manifests 10 to 25 years after the initial infection as any of the following: Aneurysmal dilation of the ascending aorta Insufficiency of the aortic valve Narrowing of the coronary arteries Pulsations of the dilated aorta may cause symptoms by compressing or eroding adjacent structures in the chest. Symptoms include brassy cough and obstruction of breathing due to pressure on the trachea, hoarseness due to vocal cord paralysis resulting from compression of the left laryngeal nerve, and painful erosion of the sternum and ribs or spine. Neurosyphilishas several forms: Asymptomatic neurosyphilis Meningovascular neurosyphilis Parenchymatous neurosyphilis Tabes dorsalis causes mild Overview of Meningitis in about 15% of patients originally diagnosed as having latent syphilis, in 25 to 40% of those with secondary syphilis, in 12% of those with cardiovascular syphilis, and in 5% of those with benign tertiary syphilis. Without treatment, it evolves to symptomatic neurosyphilis in 5%. If cerebrospinal fluid (CSF) examination does not detect evidence of meningitis 2 years after the initial infection, neurosyphilis is unlikely to develop. Meningovascular neurosyphilisresults from inflammation of large- to medium-sized arteries of the brain or spinal cord; symptoms typically occur 5 to 10 years after infection and range from none to strokes. Initial symptoms may include headache, neck stiffness, dizziness, behavioral abnormalities, poor concentration, memory loss, lassitude, insomnia, and blurred vision. Spinal cord involvement may cause weakness and wasting of shoulder-girdle and arm muscles, slowly progressive leg weakness with urinary or fecal incontinence or both, and, rarely, sudden paralysis of the legs due to thrombosis of spinal arteries. Parenchymatous neurosyphilis(general paresis, or dementia paralytica) results when chronic meningoencephalitis causes destruction of cortical parenchyma. It usually develops 15 to 20 years after initial infection and typically does not affect patients before their 40s or 50s. Behavior progressively deteriorates, sometimes mimicking a mental disorder or dementia. Irritability, difficulty concentrating, deterioration of memory, defective judgment, headaches, insomnia, fatigue, and lethargy are common; seizures, aphasia, and transient hemiparesis are possible. Hygiene and grooming deteriorate. Patients may become emotionally unstable and depressed and have delusions of grandeur with lack of insight; wasting may occur. Tremors of the mouth, tongue, outstretched hands, and whole body may occur; other signs include pupillary abnormalities, dysarthria, hyperreflexia, and, in some patients, extensor plantar responses. Handwriting is usually shaky and illegible. Tabes dorsalis(locomotor ataxia) involves slow, progressive degeneration of the posterior columns and nerve roots. It typically develops 20 to 30 years after initial infection; mechanism is unknown. Usually, the earliest, most characteristic symptom is an intense, stabbing (lightning) pain in the back and legs that recurs irregularly with loss of vibratory sense, proprioception, and reflexes in the lower extremities. Gait ataxia, hyperesthesia, and paresthesia may produce a sensation of walking on foam rubber. Loss of bladder sensation leads to urine retention, incontinence, and recurrent infections. Erectile dysfunction is common. Most patients with tabes dorsalis are thin and have characteristic sad facies and Argyll Robertson pupils (pupils that accommodate for near vision but do not respond to light). Optic atrophy may occur. Examination of the legs detects hypotonia, hyporeflexia, impaired vibratory and joint position sense, ataxia in the heel-shin test, absence of deep pain sensation, and Romberg sign. Tabes dorsalis tends to be intractable even with treatment. Visceral crises (episodic pain) are a variant of tabes dorsalis; paroxysms of pain occur in various organs, most commonly in the stomach (causing vomiting) but also in the rectum, bladder, and larynx. Syphilitic ocular and otic manifestations can occur at any stage of the disease. can affect virtually any part of the eye; they include Interstitial Keratitis , Otosyphilismay affect the cochlea (causing hearing loss and tinnitus) or vestibular system (causing vertigo and nystagmus). Trophic lesions,secondary to hypoesthesia of the skin or periarticular tissues, may develop in the later stages. Trophic ulcers may develop on the soles of the feet and penetrate as deeply as the underlying bone. Neurogenic Arthropathy None 