tertiary syphilis

Tertiary syphilis develops in approximately one-third of untreated patients, typically 10-30 years after primary infection, following the latent stage. Key manifestations include: (1) Gummas - granulomatous, necrotizing lesions that can affect skin, bone, and viscera, resulting from a delayed-type hypersensitivity reaction to the spirochete; (2) Cardiovascular syphilis - endarteritis obliterans of the vasa vasorum leads to weakening of the aortic wall, causing aortitis, aortic root dilation, aortic regurgitation, and saccular aneurysms (classically of the ascending aorta, causing a 'tree-bark' appearance on gross pathology); (3) Neurosyphilis - can present as tabes dorsalis (demyelination of dorsal columns causing sensory ataxia, loss of proprioception/vibration sense, and Romberg sign), general paresis (progressive dementia with psychiatric symptoms), meningovascular syphilis, or Argyll Robertson pupils (pupils that accommodate but do not react to light - 'prostitute's pupils' that accommodate but don't react). Diagnosis involves nontreponemal tests (RPR, VDRL) and treponemal tests (FTA-ABS, TP-PA) for confirmation; CSF analysis is needed if neurosyphilis is suspected. Treatment is high-dose IV penicillin G, though some tissue damage (especially neurological) may be irreversible. This stage is now less commonly seen in areas with widespread antibiotic use for other infections that inadvertently treat syphilis, but remains clinically relevant in HIV-positive patients and those without access to care.