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Lesionsassociatedwithtertiary syphilis developinapproximatelyonethirdofuntreatedpatients,usuallyafteralatentperiodof5yearsormore.Thesearedividedintothreemajorcategories:cardiovascularsyphilis,neurosyphilis,andso-called“benign”tertiarysyphilis, whichmayoccursinglyorincombination.Cardiovascularsyphilistakestheformofsyphilitic aortitis andaccountsformorethan80%ofcasesoftertiarydisease;itismuchmorecommoninmenthaninwomen.SyphiliticaortitisisdiscussedfurtherinChapter10.Neurosyphilis accountsfor10%ofcasesoftertiarysyphilisoverallbutoccursatincreasedfrequencyinthosewithconcomitantHIVinfection;itisdiscussedindetailinChapter22.Largeareasofparenchymaldamageintertiarysyphilisresultintheformationofagumma. Onmicroscopicexamination,thegummacontainsacentralzoneofcoagulativenecrosissurroundedbydensefibroustissuecontainingamixedinflammatoryinfiltratecomposedoflymphocytes,plasmacells,activatedmacrophages(epithelioidcells),andoccasionalgiantcells,featuresthatsuggestadelayedhypersensitivityreaction.Gummasoccurmostcommonlyinbone,skin,andthemucousmembranesoftheupperairwayandmouth,butanyorganmaybeaffected.Spirochetesareonlyrarelydemonstrable.Oncecommon,gummashavebecomeexceedinglyrarethankstoeffectiveantibioticssuchaspenicillin.TheyarereportednowmostlyinpatientswithAIDS.
Manifestationsofcongenital syphilis includestillbirth,infantilesyphilis,andlate(tardive)congenitalsyphilis.
Amonginfantswhoarestillborn,themostcommonmanifestationsarehepatomegaly,boneabnormalities,pancreaticfibrosis,andpneumonitis.Theliveroftenshowsextramedullaryhematopoiesisandportaltractinflammation.Changesinthebonesincludeinflammationanddisruptionoftheosteochondraljunctioninlongbonesand,onoccasion,boneresorptionandfibrosisoftheflatbonesoftheskull.Thelungsmaybefirmandpaleasaresultofthepresenceofinflammatorycellsandfibrosisinthealveolarsepta(pneumoniaalba).Withspecialstains,spirochetesarereadilyseenintissuesections.
Infantile syphilis referstocongenitalsyphilisininfantsthatmanifestsatbirthorwithinthefirstfewmonthsoflife.Affected infantspresentwithchronicrhinitis(snuffles)andmucocutaneouslesionssimilartothoseseeninsecondarysyphilisinadults.Visceralandskeletalchangesresemblingthoseseeninstillborninfantsalsomaybepresent.
•Late, or tardive, congenital syphilis referstocasesofuntreatedcongenitalsyphilisofmorethan2years’duration.ClassicmanifestationsincludetheHutchinsontriad:notchedcentralincisors,interstitialkeratitiswithblindness,anddeafnessfromeighthcranialnerveinjury.Otherchangesincludeaso-called“sabershin”deformitycausedbychronicinflammationoftheperiosteumofthetibia,deformedmolarteeth(“mulberrymolars”),chronicmeningitis,chorioretinitis,andgummasofthenasalboneandcartilagewitharesultant“saddlenose”deformity.