Late syphilis A52.-

Leonicenus (Leonicus), 1497

Worldwide spread, bacterial venereal disease(compulsory reporting) with typical, chronic, systemic course. Late syphilis is defined as an infectious disease > 1 year.

About 15-20% of untreated (this is no longer expected in industrialized countries) develop tertiary or late syphilis 2-40 years after infection. This is characterized by destructive syphilitic granulomas that can occur in virtually any organ. They are often misinterpreted as malignancies if the underlying diagnosis is not known. The granulomas are low in pathogens, therefore no longer contagious, and heal with scarring.

• Worldwide spread. Endemic in some areas of Eastern Europe (especially former CIS states).
• Incidence (Germany): 3.6/100,000 inhabitants/year. More common among homosexual men. S.a. Slamming.
• Up to 15% of infected persons in Germany suffer from HIV infection at the same time, up to 80% of HIV infected persons are TPHA positive(no significant difference in clinical course).

Late syphilis (syphilis III and IV):

syphilis III:

• Skin and mucous membranes: Characteristic are asymmetric, low pathogen, melting, scarring, cutaneous(tuberous syphilide, tubero-serpiginous syphilide, tubero-ulcero-serpiginous syphilide) and subcutaneous syphilides(gumma). S.a. tuberous tongue syphilis, glossitis interstitialis, glossitis interstitialis profunda.
• Syphilitic granulomas occur in liver, lung, eye, brain, bones, testicles (orchitis fibrosa specifica) in varying degrees.
• Heart: About 10% of untreated patients develop cardiovascular syphilis.
• Aorta: The aorta can lead to a syphilitic aneurysm (aneurysm dissecans), mostly in the ascending aorta,
• Neurosyphilis: Late stage of syphilis with low pathogen, vasculitic or degenerative changes in the brain and/or spinal cord (see below paralysis, progressive, tabes dorsalis).

Adults:

• Benzathine-penicillin G 2.4 million 3x i.m.(on days 1,8, and 15)
• Alternative (only for penicillin allergy): Ceftriaxone 1.0g/day i.v. over 14 days
• Alternatively (not for pregnant women): Doxycycline 100mg 2x/day p.o. for 28 days.

Children:

• As for adults with adjusted benzathine-penicillin G dose: 50.000IU/kg/application i.m. (maximum adult dose of 2.4Mio IU per application)

1. Aquilina C et al (2003) Secondary syphilis simulating oral hairy leukoplakia. J Am Acad Dermatol 49: 749-751
2. Brown DL et al (2003) Diagnosis and management of syphilis. On Fam Physician 68: 283-290
3. Buntin DM et al (1991) Sexually transmitted diseases: Bacterial infections. J Am Acad Dermatol 25: 287-299
4. Doherty L et al (2002) Syphilis: old problem, new strategy. BMY 325: 153-156
5. Golden MR et al (2003) Update on syphilis: resurgence of an old problem. JAMA 290: 1510-1514
6. Harry TC (2002) Infectious syphilis and importance of travel history. Lancet 359: 447-448
7. Lee JY, Lee ES et al (2003) Erythema multiforme-like lesions in syphilis. Br J Dermatol 149: 658-660
8. Leonicenus N (1497) De morbo gallico. Aldus Manutius, Venice
9. Potthoff A et al (2005) Syphilis and HIV infection. Characteristic features of diagnosis, clinical assessment, and treatment. Dermatologist 56: 133-140
10. Walker DG, Walker GJ (2002) Forgotten but not gone: the continuing scourge of congenital syphilis. Lancet Infect Dis 2: 432-436