Syphilis (Treponema Pallidum Infection): Clinical Presentations Through Its Stages And Phases

The incubation period varies from 1 to 3 weeks in most cases, though it may extend up to 90 days. A small macule develops at the site of inoculation which later becomes a papule and ulcerates. This is the primary chance. It presents a characteristic appearance, a punched out ulcer with a dull red areola and a clear granular base exuding colourless serum which teams with the spirochetes. The regional lymph nodes enlarge a few days later. They are discrete, rubbery in consistency and are generally described as “shotty”. Even without treatment, the chancre heals in 8 to 10 weeks leaving behind a thin scar. Even after the healing of the chancre, the lymph node enlargement persists. Generalised lymphadenopathy may develop at this stage before the secondary stage sets in.

Other ulcers occurring in the genitalia such as herpes genitalis, traumatic ulcers, chancroid, lymphogranuloma venereum, scabies and carcinoma, have to be differentiated from syphilitic chancre.

This stage develops 6 to 8 weeks after the appearance of the chancre. General symptoms such as malaise, fever, headache, anorexia, hoarseness of voice, arthralgia, nocturnal pains, generalized lymphadenopathy, jaundice and anemia develop. The skin lesions of the second stage have certain common characteristics, though some degree of variability is evident. The distinguishing features of secondary syphilitic lesions are:

1. Generalised and symmetrical distribution
2. Pink, coppery, or dusky red color
3. Absence of pruritus (pus)
4. Induration, and
5. Polymorphic (macular, popular or pustular) presentations.

Mucous membrane lesions: Condylomata lata are seen in the mucocutaneous junctions. Basically, they are papules which are modified due to the constant moisture and rubbing. They are flat topped, hypertrophic fleshy masses with broad bases. They exude serum rich in treponemes. Mucousa patches and snail tract ulcers occur in the oral cavity and genitalia. Systemic manifestations of secondary syphilis include acute uveitis which may be uni- or bilateral, meningitis and hepatitis.

Late syphilis: About 3 to 12 months after the primary and secondary stages, which are easily distinguishable, the disease enters the latent phase, The first two years period of the latent phase is termed the early latent phase. The organisms are present deep in the tissues and the only evidence of infection is the positive serology. Syphilis may remain latent for months or years or even for the whole of the patient’s life. In the early part of the latent phase, the patient may be infective, but the infectivity diminished with time.

During this stage, typical destructive lesions called “gummata” develop. These are granulomas which may be single or multiple. Histologically, the lesion shows perivascular infiltration by lymphocytes and plasma cells, followed later by fibrosis. Gummata may occur on the kin, mucous membranes, subcutaneous tissue, bones or viscera. These are asymmetric, small to large in size, and indolent with a tendency for healing in the center and spreading at the periphery.

Bone lesions: Bony lesions occur more commonly in men than in women and the symptoms are very variable and are likely to be missed if clinical suspicion is not strong. The tibia, skull, clavicle and femur are affected most, but any bone may be involved. Two types of lesions may develop- granulomatous periosteitis and gummatous osteitis. Periosteitis leads to bony proliferation and deposition of new bone beneath the periosteum. Gummatous osteitis produces circumscribed areas of osteolysis surrounded by areas of sclerosis, syphilitic osteitis and periosteitis may occur in the same bone.

Visceral Syphilis: Liver is affected most commonly, and it is enlarged by multiple gummata. As the lesions heal, sheets of fibrous tissue are formed and the liver is shrunken and distorted. The surface of the liver becomes lobular and this is termed “hepar lobatum”. Stomach, intestines, lungs and reproductive organs are affected less commonly. Cardiovascular and central nervous system lesions occur at this stage. Cardiovascular lesions include syphilitic aortitis, aortic regurgitation and aneurysms of the aorta. Neurological involvement is more varied and this may be meningovascular or parenchymal. Meningitis occurs. In the secondary stage, but in the tertiary stage, meningovascular involvement leads to meningomyelitis, transverse myelitis, syphilitic pachymeningitis, Erb’s syphilitic paraplegia and occlusive vascular lesions. Parenchymal lesions are tabes dorsalis, general paralysis of the insame (GPI), taboparesis and optic atrophy.