Gummas

Tertiary syphilis develops in about a third of untreated patients after a latent period of years to decades and takes three forms: gummatous syphilis, cardiovascular syphilis, and neurosyphilis. Gummas are granulomas with a centre of coagulative necrosis surrounded by palisading macrophages, lymphocytes, and plasma cells, with obliterative endarteritis of small vessels; plasma cell infiltration and endarteritis are the histological signature of syphilis at every stage. They are destructive but contain few organisms, and they most often involve skin, producing painless ulcerating nodules, and bone, producing periostitis and the classic saber shin, and may also affect liver (hepar lobatum), testis, and brain. Cardiovascular syphilis affects the vasa vasorum of the ascending aorta, causing aortitis, a tree-bark intimal appearance, aortic root dilatation with regurgitation, and aneurysm. Diagnosis uses non-treponemal screening (RPR, VDRL) confirmed by treponemal tests, and penicillin G remains the treatment for all stages.