Tertiary period of syphilis (syphilis tertiaria)

In distinction from the secondary period, the clinical manifestations in tertiary syphilis are prevalently local, often with involvement not only of the skin and mucous membranes, but of the internal organs, nervous system and motor apparatus; a scar remains after the lesions resolve. The pathoanatomical essence of tertiary syphilids is an infectious granuloma whose localization in some cases leads to impaired function of the organ in which it has formed.

The tertiary period of syphilis is subdivided into active tertiary syphilis and latent tertiary syphilis.

Involvement of the skin and mucous membranes (tertiary syphilids) may be displayed by tubercles or gumma (gummata) on the skin, in the subcutaneous tissue, muscles, bones, internal organs and nervous system.

Only a small number of the lesions form (tubercles form in dozens while gummata are usually solitary). They follow a malignant course and always leave scars (if localized in vitally important organs they create a threat to the patient's life). If no treatment is applied, the lesions heal very slowly. They are not very contagious (treponemas are few in number and contained deep in the infiltrate) and respond well to antisyphilitic treatment, particularly with iodine preparations and salts of heavy metals. It should be borne in mind that in the tertiary period standard serological reactions are negative in 25 to 35 per cent of patients. The results of blood tests for T. pallidum immobilization, which are very rarely negative in the tertiary period, are of immense diagnostic value in such cases.

Tubercular Syphilid (Syphilis Tuberculosa)

Tubercular syphilid is usually localized on a small skin area, asymmetrically as a rule. The tubercle is semispherical or flat, copper-red with a cyanotic hue, and the size of a cherry stone. It is hard and has discrete boundaries. The infiltrate of the syphilitic tubercle undergoes necrosis either of the dry type or with the formation of ulcers. In the first case atrophy remains after the tubercle resolved. In the second case the ulcers leave a slightly retracted focus of grouped scars surrounded by a pigmented ring. The tubercles erupt in bouts and are therefore found in different stages of resolution. As a result a 'tesselated scar' forms (particularly often after a grouped tubercular syphilid) which many years later confirms the fact that the patient had suffered from tertiary tubercular syphilis. Most frequent occurrences are grouped tubercular syphilid, in which the tubercles are arranged in a cluster, or group without coalescing, and serpiginous (creeping) tubercular syphilid, in which the tubercles coalesce, heal in the centre while new tubercles appear on the periphery of the focus. Tubercular syphilid, in which the tubercles coalesce into a single patch, and dwarf syphilitic tubercles resembling a millet grain in size are encountered less frequently. Tubercular syphilid causes no subjective disorders.

Tubercular syphilid has to be differentiated first of all from lupus vulgaris in which the tubercles (lupomas) are soft (because of this the 'probe' phenomenon or Pospelov's sign is positive, i.e. the lupoma is easily pierced with a blunt probe or its soft tissue is easily pitted) and coloured light-red with a yellowish tinge well demonstrated in diascopy ('apple-jelly' phenomenon, 'apple mousse' sign). In lupus vulgaris the tubercles are usually flatter, only slightly elevated above the skin surface, and tend to coalesce into foci of extensive affection with ultimate formation of a vast depigmented atrophic scar, in the thickness of which new lupomas often develop. When the lupomas necrotize, ulcers with irregular and eroded contours form, they are reddish-cyanotic with soft irregular edges and often with a granular floor. Lupus vulgaris lasts several years. The syphilitic tubercles are hard, ham-red or intensively red in colour and are usually grouped in a focus without coalescing. If the tubercles in syphilis ulcerate, the ulcers have regular round contours, sloping uneroded edges, a clean and smooth floor and a dense-elastic infiltrate in the base. The scars remaining after syphilitic tubercles are mottled in colour because of irregular pigmentation and uneven in relief ('tesselated scars'); new tubercles never form on them. The disease lasts weeks or months, rarely longer.

Serological reactions, which are positive in some patients, as well as the T, pallidum immobilization and immunofluorescence tests, which are positive in most patients, and, finally, the efficacy of trial antisyphilitic treatment help in recognizing tubercular syphilid.