SIGNS AND SYMPTOMS
In cases of congenital syphilis, the patient may manifest Hutchinson's triad (interstitial keratitis, deafness and malformed teeth), osteochondritis (inflammation of both bone and cartilage), chorioretinitis, hepatosplenomegaly (enlargement of the liver and spleen), and anorexia.
In the primary stage of acquired syphilis, the patient develops a painless chancre at the site of inoculation, as well as regional lymphadenopathy. While primarily genital, chancres may develop on the eyelid and conjunctiva. Other ocular signs in the primary stage include conjunctivitis, blepharitis, and alopecia.
In the secondary stage of acquired syphilis, the patient will develop malaise, lymphadenopathy, fever, maculopapular skin lesions on the palms and soles, joint pain, headache, and loss of appetite. Ocular signs are most common in secondary syphilis and include episcleritis, anterior uveitis, uveitic glaucoma, neuroretinitis, chorioretinitis, ischemic retinal vasculopathy, and infectious optic neuropathy.
In the third stage of acquired syphilis, focal endarteritis causes the
formation of gummas (granulomatous lesions), which can involve the eye and adnexa, and the
central nervous and cardiovascular systems. At this stage, neurosyphilis can manifest with
acute meningitis, cranial neuropathies, optic atrophy, pupil abnormalities, paresis, and
tabes dorsalis (degeneration of the dorsal columns of the spinal cord resulting in loss of
coordination, reflexes and sensation, and ataxic gait).
After infection, a period of incubation ensues. The organism enters the lymphatic system and bloodstream and disseminates soon after contact. Shortly after infection, a chancre forms at the site of inoculation. The chancres spontaneously heal after two to eight weeks, and the patient enters the secondary stage of syphilis. In individuals with an intact immune system, the disease enters a period of latency. Inflammation and regional vasculopathy account for the signs and symptoms.
After a period of latency (which may extend four or more years in an
untreated or undertreated individual), the patient enters the tertiary stage. Focal
granulomatous lesions known as gummas develop and can affect virtually any organ system.
The resultant dysfunction caused by these gummas accounts for the dysfunction seen in
tertiary syphilis. Approximately 10 percent of untreated patients develop neurosyphilis.
Since the organism has a predilection for the dorsal spinal cord and intercalated neurons,
these patients can develop an ataxic gait and loss of sensation from the lower limbs, and
light-near dissociated pupils, which are often miotic (Argyll Robertson pupils). If left
untreated, dysfunction of the central nervous and cardiovascular systems can lead to
progressive dementia and death.
Tests specific for antibodies to Treponema pallidum include the fluorescent treponemal antibody absorption (FTA-ABS) and microhemagglutination assay for Treponemal pallidum (MHA-TP). These tests indicate whether or not antibodies are present from a previous syphilitic infection, but do not indicate current disease activity. There is a lower incidence of false-positive results with these specific tests. When you suspect syphilis, order both a specific and a non-specific test. In cases where serologic results are uncertain, these tests can be performed using cerebrospinal fluid.
Treatment of syphilis involves systemic IV or IM penicillin.
Alternatives for penicillin-sensitive patients include doxycyline, tetracycline,
ceftriaxone, and chloramphenicol. In neurosyphilis, there is no acceptable substitute, and
patients must be desensitized to penicillin prior to treatment.
Other reports in this section
Eyelids & Eyelashes | Conjunctiva & Sclera | Cornea
Uvea | Vitreous & Retina | Optic Nerve & Brain | Oculosystemic Disease
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