What are the other Names for this Condition? (Also known as/Synonyms)

• Infection by Treponema Pallidum – Tertiary Syphilis
• Late (Tertiary) Syphilis
• Late Syphilis

What is Tertiary Syphilis? (Definition/Background Information)

• Syphilis is a very common infectious disease caused by the bacterium Treponema pallidum. Syphilis is generally transmitted through sexual contact. A pregnant woman affected by Syphilis can transmit the infection to her child through the placenta, while the baby is still in the womb
• The disease leads to formation of lesions on the body, especially around the anus, genitalia, and mouth. Any contact with these ulcerative lesions result in a transmission of the condition
• There are 3 stages in the progression of Syphilis; Primary, Secondary, and Tertiary. The sooner the treatment is started, better is the outcome. If treatment is delayed or is lacking; it could develop into a serious medical issue with long-term neurological complications. In rare cases, the complications can even lead to death
• The universal treatment for this condition (at all stages) is by using the drug penicillin, which can bring about a complete recovery. However, early recognition and management of the condition is extremely important

Primary stage: After the initial infection (direct sexual contact with affected individual), the bacterium spreads all over the body using the blood vessels and lymphatic system, and multiply rapidly. Primary lesions form within a few hours after infection, which contain large quantities of the Treponema bacteria.

Secondary stage: The bacterium invades tissues, cerebrospinal fluid, skin, and mucus membranes. It causes inflammatory rashes on the body (secondary lesions), within 4-12 weeks after the primary stage. This continues till a stage of dormancy is reached; after which multiple relapse or remissions take place (for the next 1-2 years).

Tertiary stage: After the secondary stage, there is a period of latency, which could last for many years. A third of all infections, then gradually progresses to Tertiary Syphilis. In this stage, the central nervous system is affected and several vital organs (heart, liver) may develop infections. This may take place after 3 years or sometimes even after 20 years. Tertiary Syphilis is classified into three key types, principally based on the infestation location. These are: Neurosyphilis, Cardiovascular Syphilis, and Gummatous Syphilis

Who gets Tertiary Syphilis? (Age and Sex Distribution)

• Sexually mature men and women who are infected by Treponema bacteria contract Syphilis. Occasionally, even teenagers (as young as 15 years) are affected by this infectious condition
• No gender preference or racial predilection is observed. However, according to a CDC report (CDC.gov release, 2006) the male-female incidence for Syphilis - Primary & Secondary, stands at 6:1. The male-female ratio for an untreated Syphilis developing to Tertiary Syphilis is around 2:1
• However, in certain geographical regions with lower socio-economic standards and insufficient access to proper healthcare; it is found that the general incidence of sexually transmitted diseases (STDs), including Syphilis is higher

What are the Risk Factors for Tertiary Syphilis? (Predisposing Factors)

Risk factors for Syphilis include:

• Having a new sex partner (a carrier of Syphilis)
• Multiple sex partners
• Not practicing safe sex
• Having sex with individuals who have STDs
• Having a same-sex partner(s). The incidence of Syphilis is extremely high among men (according to a CDC study, up to 72% of all new cases in 2011, were owing to this single factor)
• Increased use of drugs (cocaine, methamphetamine, Viagra); leading to high-risk behavior, such as ‘sex for drugs’
• Untreated pregnant women with syphilis, have a very high risk (90% chance) of passing on the infectious bacteria to the baby in the womb. This causes Congenital Syphilis
• Transfusion of contaminated blood or blood products (contaminated by the syphilitic bacteria)

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Tertiary Syphilis? (Etiology)

• Syphilis is a contagious bacterial infection that is transmitted through sex with an affected individual. It is caused by the bacterium Treponema pallidum
• An individual’s skin lesions and mucus membranes carry the pathogen, which then spreads to their partner(s) during all forms of sexual contact (even through kissing), causing an infection. It infects the mouth, anus, and genitals of males and females
• Syphilis has three distinct stages of progression; each stage more aggressive than the previous one: Primary, Secondary, and Tertiary

What are the Signs and Symptoms of Tertiary Syphilis?

Each stage of Syphilis presents a different set of signs and symptoms. The progression to higher stages occurs because of non-treatment. These include:

Syphilis – Primary:

• Formation of small, painless sores (called chancres) on the genitals or anus, that remain unnoticed sometimes
• The sores maybe solitary or multiple, and may take anywhere from 3-90 days to appear. It then forms into a tender blister, erupts, and ulcerates (with loss of skin, tissue, and formation of pus). After this, the sores heal within 3-6 weeks
• Lymph node inflammation around the infected region, is normally observed

Syphilis – Secondary: Many individuals do not report a Primary stage, since they remain unaware of such a stage.

• Formation of red skin rashes (that appear inflamed and wart-like), on the entire body including the palms and soles. The lesions are also observed around the genitals, anus, and mouth
• The rashes form blisters, which become tender and erupt, oozing pus. Itching or burning sensations are usually absent. Hair loss is observed around these blisters
• Fever, muscular pain, headaches
• Fatigue, lethargy, weight loss
• Sore throat
• Inflamed lymph nodes
• The symptoms may last a few weeks (3-6 weeks) and resolve automatically, even without any treatment. But thereafter, these recur repeatedly for about a year or two in most individuals

After the secondary stage, there is a latent stage, known as Asymptomatic Syphilis which may last for many years (even decades). All infections do not progress to the final (tertiary) stage.

Tertiary stage: About 30% of untreated Syphilis cases move into this final non-infectious state, which is also known as Late Syphilis. The central nervous system is affected, several vital organs (such as the heart and liver) may develop infections, and nerve cells are permanently destroyed. This takes place between 3-15 years, sometimes even two decades after the infection was first contracted.

Tertiary Syphilis is classified into three key types, principally based on the infestation location. These are not mutually exclusive and hence, they can all be present together, at the same time. Some forms may be more dominant than the other:

• Neurosyphilis: Severe infection of the central nervous system is observed. It is divided into 6 categories
• Cardiovascular Syphilis: Causing aortic aneurysms and regurgitation
• Gummatous (late benign) Syphilis: Characterized by the presence of soft tumor-like gummas

Syphilis – Tertiary:

• Presence of multiple soft tumors (termed as gummas), chiefly on the face and brain, skin (superficial tumors, may be solitary or multiple), long bones, lung, and liver
• Neurological abnormalities; paralysis, numbness, muscle coordination problems, abnormal reflexive actions, dementia, psychosis
• Vital organs such as brain, heart, liver, and blood vessels are severely affected
• Aortic inflammation, aneurysms, and regurgitation
• Bone and joint pain
• Hearing loss (partial or complete)
• Vision problems (blindness, corneal clouding)
• Gummas in the gastrointestinal system (stomach, intestine) cause weight loss, feeling of fullness after consuming very little food, abdominal pain, belching

How is Tertiary Syphilis Diagnosed?

Diagnosis of the condition may be made at any stage of the disease. A few diagnostic tests performed for Syphilis include the following:

• Physical exam with evaluation of medical history
• Blood test, for detecting antibodies against Syphilis
• Exam of cerebrospinal fluid (lumbar puncture); in case of Neurosyphilis
• Analysis of lesion fluids in the laboratory, under a microscope (dark field microscopy)

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Tertiary Syphilis?

Complications due to Syphilis (Tertiary stage) are mainly due to the formation of destructive tumors resulting in severe neurological abnormalities, which can cause life-threatening situations. These include:

• Destructive lesions (tumors) of the bones causing arthritis, bones soften and deform, inflammation of connective tissues surrounding the bones; accompanied by severe pain
• Facial deformity due to formation of soft tissue tumors
• Infiltration of tumorous growths in the lungs, pharynx, and trachea leading to respiratory problems, wheezing, hoarseness
• Severe neurological abnormalities, permanent loss of certain brain functions (like memory, thinking capacity, language, behavior), tumors of the central nervous system
• Complete loss of vision, hearing
• Cardiovascular related disorders: Narrowing of the arteries, heart failure, heart attack, angina (chest pain)

How is Tertiary Syphilis Treated?

Prompt, early diagnosis and appropriate treatment is the key to speedy recovery from Syphilis. However, with Syphilis – Tertiary, the bacterial infection has developed to a late stage (over many years) from which complete recovery with 100% return of normal body and brain function may not be possible. But, further advancement of Syphilis can be arrested, and fatalities avoided. The treatment measures include:

• All manifestations of syphilis are treated using the antibiotic drug penicillin. This is given as an intramuscular injection (for a couple of weeks), or intravenously. Worldwide, penicillin is a cheap and easily available drug that is also simple to administer
• If the individual is allergic to penicillin, then it is given in very small dosages and in a controlled manner, until the body gets sensitized (accustomed) to the drug

How can Tertiary Syphilis be Prevented?

• Syphilis is classified as a venereal disease (VD) transmitted from one individual to another. This occurs during sexual contact with the infected lesions. It is a preventable and curable disease

The onus is on all sexually mature individuals to ensure that they are generally well-informed (either by their healthcare providers or public health authorities) of the sexually transmitted syphilitic infection. They have to be also aware of the preventive measures and precautions to be taken, which include:

• Avoidance of multiple sex partners
• Practice of safe sex (use of condoms that prevent entry of the syphilis bacteria)
• Excessive craving for drugs and alcohol, may lead to unsafe practices, such as ‘sex for drugs’
• If you are frequently sexually active with multiple partners; then regular screening for sexually transmitted diseases is essential

What is the Prognosis of Tertiary Syphilis? (Outcomes/Resolutions)

• In many cases, Syphilis – Tertiary (stage) can be completely treated; if an early diagnosis and proper treatment is rendered. Nevertheless, on account of late management of the condition; damage to the central nervous system, bones, heart, lungs, and GI system may be permanent. The extent of the damage depends on many factors and other underlying disorders (if any present)
• The condition of infected individuals without any treatment will progressively worsen with the final/tertiary stage. In such cases the outcome is poor. Death may result from respiratory, neurological, cardiovascular, or liver complications
• The outcomes are poorer in individuals diagnosed with AIDS/HIV infection, or other opportunistic infections

Additional and Relevant Useful Information for Tertiary Syphilis:

• If you are diagnosed with Syphilis (or other VDs), then inform of the condition to your sex partner(s). Abstain completely from sex until you are certified cured
• Given the fact that there may be many years of symptom-free (latent) period; it is particularly important that regular screening and blood tests for Syphilis are undertaken
• Pregnant women with untreated Syphilis can infect the baby in the womb. Hence, it is recommended that all pregnant women should undergo screening tests for Syphilis
• Syphilis does not spread by non-human contact such as spas, hot tubs, toilet seats, and swimming pools
• Syphilitic sores (oral, anal, penile, or vaginal) can increase the risk for acquiring HIV infections. CDC reports that such a risk of acquiring an HIV infection, is increased 2-5 times
• There are no home remedies to treat Syphilis
• The treatment provided, even if it is during the later stages, helps prevent the infection from causing further damage. The damage to organs already occurred, cannot be reversed
• It is important to note that Syphilis can reinfect a person even after successful treatment for a prior infection. Infection by Syphilis does not confer a lifelong immunity